1. Ingeniería

LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
A4206 09
A4207 09
A4208 09
A4209 09
A4210 09
A4212 09
A4213 09
A4215 09
A4221 07
A4221 09
A4222 07
A4222 09
A4230 09
A4231 09
A4233 09
A4234 09
A4235 09
A4236 09
A4244 09
A4245 09
A4246 09
A4310 09
A4311 09
A4320 09
A4322 09
A4326 09
A4327 09
A4328 09
A4331 09
A4332 09
A4335 09
A4336 09
A4338 09
A4344 09
A4349 09
A4351 09
A4352 09
A4353 09
A4354 09
A4355 09
A4356 09
A4357 09
A4358 09
A4360 09
A4361 09
A4362 09
A4364 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
SYRINGE WITH NEEDLE, STERILE 1CC
SYRINGE WITH NEEDLE, STERILE 2CC
SYRINGE WITH NEEDLE, STERILE 3CC
SYRINGE W/ NEEDLE, STERILE 5CC OR GR
NEEDLE-FREE INJECTION DEVICE
HUBER-TYPE NEEDLE, EACH
SYRINGE, STERILE, 20 CC OR GREATER
NEEDLES ONLY, STERILE, ANY SIZE
SUPPLIES FOR DRUGS INF CATH,PER WEEK
SUPPLIES FOR DRUG INF. CATH,PER WEEK
SUPPLIES FOR EXTERNAL DRUG INF PUMP
SUPPLIES FOR EXTERNAL DRUG INF PUMP
INFUSION SET FOR EXT INSULIN PUMP
INFUSION SET FOR EXT INSULIN PUMP
ALKALINE BATTERY FOR GLUCOSE MONITOR
J-CELL BATTERY FOR GLUCOSE MONITOR
LITHIUM BATTER FOR GLUCOSE MONITOR
SILVER OXIDE BATTERY FOR GLUCOSE
ALCOHOL OR PEROXIDE, PER PINT
ALCOHOL WIPES, PER BOX
ALCOHOL OR PEROXIDE, PER BOTTLE
INSERTION TRAY ONLY
INSERTION TRAY W/O DRAUB BAG W FOLEY
CATHETER IRRIGATION WITH BULB SYRING
IRRIGATION SYRINGE, BULB OR PISTON
MALE EXTERNAL CATHETER SPECIALTY TYP
FEMALE EXTERNAL URINARY COLLECTION D
FEMALE EXTERNAL URINARY COLLECTION D
EXTENSION DRAINAGE TUBING
LUBRICANT FOR CATH INSERTION
INCONTINENCE SUPPLY; MISCELLANEOUS
INCONTINENCE SUPPLY, URETHRAL INSERT
INDWELLING CATHETER FOLEY TYPE
INDWELLING CATH, FOLEY,2-WAY,SILICON
DISPOSABLE MALE EXTERNAL CATHETERS
INTERMITTENT URINARY CATHETER; STRAI
INTERMITTENT URINARY CATHETER; COUDE
INTERMITTENT URINARY CATH W INS SUPP
INSERTION TRAY W/ DRAIN BAG
3-WAY IRRIGATION SET FOR CATHETER
INCONTINENCE CLAMP
URINARY DRAINAGE BAG
URINARY LEG BAG W/OR W/O TUBE
DISPOSABLE EXTERNAL URETHRAL CLAMP
OSTOMY FACE PLATE
OSTOMY SKIN BARRIER
OSTOMY SKIN BOND OR CEMENT
4
FEE
MP
MP
MP
MP
1.74
5.44
MP
MP
MP
MP
MP
MP
MP
MP
.49
2.24
1.44
1.04
MP
MP
MP
3.71
10.24
3.25
MP
6.59
27.25
6.18
1.95
.13
MP
MP
6.53
10.26
1.33
MP
3.33
MP
7.21
MP
MP
5.93
4.05
.37
MP
MP
MP
5
ICFMR
EXEMPT
Y
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
1
2
1
2
2
2
2
2
1
1
1
2
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
1
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120901
20120901
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
A4367 09
A4368 09
A4369 09
A4371 09
A4372 09
A4373 09
A4375 09
A4376 09
A4377 09
A4378 09
A4379 09
A4380 09
A4381 09
A4382 09
A4383 09
A4384 09
A4385 09
A4387 09
A4388 09
A4389 09
A4390 09
A4391 09
A4392 09
A4393 09
A4397 09
A4398 09
A4399 09
A4400 09
A4402 09
A4404 09
A4405 09
A4406 09
A4407 09
A4408 09
A4409 09
A4410 09
A4411 09
A4413 09
A4414 09
A4415 09
A4416 09
A4417 09
A4418 09
A4419 09
A4421 09
A4422 09
A4423 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
OSTOMY BELT
OSTOMY FILTER,ANY TYPE, EACH
OSTOMY SKIN BARRIER,LIQUID,PER OZ
SKIN BARRIER POWDER PER OZ
SKIN BARRIER SOLID 4X4 EQUIV
SKIN BARRIER W FLANGE,STANDARD,EACH
DRAINABLE PLASTIC PCH W FCPL
DRAINABLE RUBBER PCH W FCPLT
DRAINABLE PLSTIC PCH W/O FP
DRAINABLE RUBBER PCH W/O FP
URINARY PLASTIC POUCH W FCPL
ILEOSTOMY SET
URINARY PLASTIC POUCH W/O FP
URINARY HVY PLSTC PCH W/O FP
URINARY RUBBER POUCH W/O FP
OSTOMY FACEPLT/SILICONE RING
OST SKN BARRIER SLD EXT WEAR
OST CLSD POUCH W ATT ST BARR
DRAINABLE PCH W EX WEAR BARR
DRAINABLE PCH W ST WEAR BARR
ILEAL BLADDER SET
URINARY POUCH W EX WEAR BARR
URINARY POUCH W ST WEAR BARR
URINE PCH W EX WEAR BAR CONV
IRRIGATION SUPPLY; SLEEVE
IRRIGATION SUPPLIES-BAGS
IRRIGATION SUPPLIES CONE/CATHETER
IRRIGATION SET FOR IRRIGATION OF OST
OSTOMY LUBRICANT
OSTOMY RINGS
NONPECTIN BASED OSTOMY PASTE
PECTIN BASED OSTOMY PASTE
EXT WEAR OST SKIN BARR <=4SQ"
EXT WEAR OST SKN BARR >4SQ
OST SKN BARR W FLNG <=4SQ"
OST SKN BARR W FLNG >4SQ"
OST SKIN BARR EXTND=4 SQ INCHES
2PC DRAINABLE OST POUCH
OSTOMY SKNBARR W FLNG <=4SQ"
OSTOMY SKN BARR W FLNG >4SQ"
OST PCH CLSD W BARRIER/FILTR
OST PCH W BAR/BLTINCONV/FLTR
OST PCH CLSD W/O BAR W FILTR
OST PCH FOR BAR W FLANGE/FLT
OSTOMY SUPPLY MISC
OST POUCH ABSORBENT MATERIAL
OST PCH FOR BAR W LK FL/FLTR
4
FEE
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
6.53
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
2.01
2.72
1.32
1.27
MP
MP
1.36
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
2
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
A4424 09
A4425 09
A4426 09
A4427 09
A4428 09
A4429 09
A4431 09
A4432 09
A4433 09
A4434 09
A4450 09
A4452 09
A4455 09
A4456 09
A4461 09
A4463 09
A4466 09
A4481 09
A4483 09
A4490 09
A4495 09
A4500 09
A4510 09
A4550 09
A4555 09
A4556 09
A4557 09
A4565 09
A4570 09
A4605 09
A4606 09
A4611 09
A4612 09
A4613 07
A4613 09
A4614 09
A4615 09
A4616 09
A4618 07
A4618 09
A4620 09
A4623 09
A4624 09
A4625 09
A4627 09
A4628 09
A4629 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
OST PCH DRAIN W BAR & FILTER
OST PCH DRAIN FOR BARRIER FL
OST PCH DRAIN 2 PIECE SYSTEM
OST PCH DRAIN/BARR LK FLNG/F
URINE OST POUCH W FAUCET/TAP
URINE OST POUCH W BLTINCONV
OST PCH URINE W BARRIER/TAPV
OSTOMY POUCH URINE W BAR/FLANGE/TAP
URINE OST PCH BAR W LOCK FLN
OST PCH URINE W LOCK FLNG/FT
TAPE NON-WATERPROOF PER 18 SQ INCHES
WATERPROOF TAPE
ADHESIVE REMOVER OR SOLVENT (FOR TAP
ADHESIVE REMOVER, WIPES, ANY TYPE, E
SURGICAL DRESSING HOLDER, NON-REUSAB
SURGICAL DRESSING HOLDER, REUSABLE,
GARMENT, BELT, SLEEVE OR OTHER COVER
TRACHEOSTOMA FILTER
MOISTURE EXCHANGER
SURGICAL STOCKINGS ABOVE KNEE LENGTH
SURGICAL STOCKINGS THIGH LENGTH, EAC
SURGICAL STOCKINGS BELOW KNEE EACH
SURGICAL STOCKINGS FULL LENGTH, EACH
SURGICAL TRAYS
ELECTRODE TRANSDUCER USE WITH ELL ST
ELECTRODES, (E.G., APNEA MONITOR)
LEAD WIRES, (E.G., APNEA MONITOR)
SLINGS
SPLINT
TRACH SUCTION CATH CLOSE SYS
OXYGEN PROBE & USE W OXIMETER DEVICE
BATTERY,HEAVY DUTY, REPLACEMENT FOR
BATTERY CABLES; REPLACEMENT FOR PATI
BATTERY CHARGER
BATTERY CHARGER; REPLACEMENT FOR PAT
HAND-HELD PEFR METER
CANNULA, NASAL
TUBING (OXYGEN), PER FOOT
BREATHING CIRCUITS
BREATHING CIRCUITS
VARIABLE CONCENTRATION MASK
TRACHEOSTOMY, INNER CANNULA (REPLACE
TRACH SUCTION CATH - EACH
TRACHEOSTOMY CARE OR CLEANING STARTE
SPACER, BAG OR RESERVOIR, WITH OR WI
OROPHARYNGEAL SUCTION CATH
TRACHEOSTOMY CARE KIT
4
FEE
3.48
2.62
1.73
2.03
4.76
6.04
4.55
MP
2.45
2.74
MP
MP
MP
.18
2.11
8.51
MP
MP
MP
45.91
54.38
35.39
69.22
MP
.56
MP
MP
8.83
MP
15.06
182.01
144.45
73.42
13.25
132.46
22.90
MP
MP
MP
MP
4.44
MP
1.69
MP
30.82
MP
3.83
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
8
AGE
RESTRICTION
Y
Y
Y
1
1
1
1
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
1
1
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
00
00
2
20
20
REPORT NO:
RF-0-76D
PAGE:
3
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20140101
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
A4635 09
A4636 09
A4637 09
A4640 09
A4649 09
A4660 09
A4663 09
A4670 09
A4680 09
A4690 09
A4730 09
A4740 09
A4750 09
A4755 09
A4760 09
A4765 09
A4770 09
A4771 09
A4860 09
A4913 09
A4918 09
A4927 09
A4930 09
A5051 09
A5052 09
A5053 09
A5054 09
A5055 09
A5061 09
A5062 09
A5063 09
A5071 09
A5072 09
A5073 09
A5081 09
A5082 09
A5093 09
A5102 09
A5105 09
A5112 09
A5113 09
A5114 09
A5120 09
A5121 09
A5122 09
A5126 09
A5500 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
UNDERARM PAD CRUTCH REPLACEMENT EACH
REPLACE HANDGRIP CANE CRUT WALK EAC
REPLACEMENT TIP CANE CRUTCH R WALKER
ALTERNATING PRESSURE PAD
SURGICAL SUPPLIES NOT ELSEWHERE CLAS
SPHYGMOMANOMETER/BLOOD PRESSURE APPA
BLOOD PRESSURE CUFF ONLY
AUTOMATIC BLOOD PRESSURE MONITOR
ACTIVATED CARBON FILTERS FOR DIALYSI
DIALYZER'S (ARTIFICIAL KIDNEY'S) AL
FISTULA CANNULATION SET FOR DIALYSIS
SHUNT ACCESSORIES FOR DIALYSIS ONLY
BLOOD TUBING, ARTERIAL OR VENOUS, E
BLOOD TUBING, ARTERIAL AND VENOUS C
DIALYSATE STANDARD TESTING SOLUTION
DIALYSATE CONCENTRATE ADDITIVES, EA
BLOOD TESTING SUPPLIES (E.G. VACUTA
SERUM CLOTTING TIME TUBE, PER BOX
DISPOSABLE CATHETER CAPS
MISCELLANEOUS DIALYSIS SUPPLIES, NO
VENOUS PRESSURE CLAMPS, EACH
GLOVES NON STERILE PER 100
GLOVES, STERILE, PER PAIR
CLOSED POUCH W/BARRIER ATTACHED
CLOSED POUCH W/O BARRIER ATTACHED
CLOSED POUCH FOR USE ON FACE PLATE
CLOSED POUCH FOR USE ON BARR W/FLANG
STOMA CAP
DRAINABLE POUCH W/BARRIER ATTACHED
DRAIN POUCH W/O BARRIER ATTACHED
DRAIN POUCH FOR USE ON BARR W/FLANGE
URINARY POUCH W/BARRIER ATTACHED
URINARY POUCH W/O BARRIER ATTACHED
URINARY POUCH FOR USE ON BARRIER W F
STOMA PLUG OR SEAL, ANY TYPE
CONTINENT DEVICE; CATHETER FOR CONTI
OSTOMY ACCESSORY; CONVEX INSERT
BEDSIDE DRAINAGE BOTTLE, RIGID OR EX
URINARY SUSPENSORY; WITH LEG BAG, WI
URINARY LEG BAG; LATEX
LEG STRAP; LATEX, PER SET
LEG STRAP; FOAM OR FABRIC, PER SET
SKIN BARRIER WIPES OR SWABS
SKIN BARRIER SOLID 6X6
SKIN BARRIER SOLID 8X8
ADHESIVE; DISC OR FOAM PAD
DIAB SHOE FOR DENSITY INSERT
4
FEE
3.66
3.54
MP
46.97
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
6.40
.35
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
13.79
24.00
21.14
2.87
5.45
.16
MP
MP
MP
52.53
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
1
1
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
4
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
A5501 09
A5503 09
A5504 09
A5505 09
A5506 09
A5507 09
A5508 09
A5510 09
A5512 09
A5513 09
A6021 09
A6022 09
A6023 09
A6024 09
A6025 09
A6154 09
A6196 09
A6197 09
A6198 09
A6199 09
A6203 09
A6204 09
A6205 09
A6206 09
A6207 09
A6208 09
A6209 09
A6210 09
A6211 09
A6212 09
A6213 09
A6214 09
A6215 09
A6216 09
A6217 09
A6218 09
A6219 09
A6220 09
A6221 09
A6222 09
A6223 09
A6224 09
A6228 09
A6229 09
A6230 09
A6234 09
A6235 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
DIABETIC CUSTOM MOLDED SHOE
DIABETIC SHOE W/ROLLER/ROCKR
DIABETIC SHOE WITH WEDGE
DIAB SHOE W/METATARSAL BAR
DIABETIC SHOE W/OFF SET HEEL
MODIFICATION DIABETIC SHOE
DIABETIC DELUXE SHOE, PER SHOE
DIEBETIC SHOE DIRECT FORMED PRE FAB
DIABETIC SHOE DIRECT FORMED W HEAT P
DIABETIC SHOE CUSTOM MOLDED
COLLAGEN DRESSING <=16 SQ IN
COLLAGEN DRSG>6<=48 SQ IN
COLLAGEN DRESSING >48 SQ IN
COLLAGEN DSG WOUND FILLER
SILICONE GEL SHEET, EACH
WOUND POUCH EACH
ALGINATE DRESSING <=16 SQ IN
ALGINATE DRSG >16 <=48 SQ IN
ALGINATE DRESSING > 48 SQ IN
ALGINATE DRSG WOUND FILLER
COMPOSITE DRSG <= 16 SQ IN
COMPOSITE DRSG >16<=48 SQ IN
COMPOSITE DRSG > 48 SQ IN
CONTACT LAYER <= 16 SQ IN
CONTACT LAYER >16<= 48 SQ IN
CONTACT LAYER > 48 SQ IN
FOAM DRSG <=16 SQ IN W/O BDR
FOAM DRG >16<=48 SQ IN W/O B
FOAM DRG > 48 SQ IN W/O BRDR
FOAM DRG <=16 SQ IN W/BORDER
FOAM DRG >16<=48 SQ IN W/BDR
FOAM DRG > 48 SQ IN W/BORDER
FOAM DRESSING WOUND FILLER
NON-STERILE GAUZE<=16 SQ IN
NON-STERILE GAUZE>16<=48 SQ
NON-STERILE GAUZE > 48 SQ IN
GAUZE <= 16 SQ IN W/BORDER
GAUZE >16 <=48 SQ IN W/BORDR
GAUZE > 48 SQ IN W/BORDER
GAUZE <=16 IN NO W/SAL W/O B
GAUZE >16<=48 NO W/SAL W/O B
GAUZE > 48 IN NO W/SAL W/O B
GAUZE <= 16 SQ IN WATER/SAL
GAUZE >16<=48 SQ IN WATR/SAL
GAUZE > 48 SQ IN WATER/SALNE
HYDROCOLLD DRG <=16 W/O BDR
HYDROCOLLD DRG >16<=48 W/O B
4
FEE
155.17
25.16
26.48
26.48
26.48
26.48
28.25
26.16
20.06
29.94
15.81
15.81
143.09
4.66
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
5
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
A6236 09
A6237 09
A6238 09
A6240 09
A6241 09
A6242 09
A6243 09
A6244 09
A6245 09
A6246 09
A6247 09
A6248 09
A6250 09
A6251 09
A6252 09
A6253 09
A6254 09
A6255 09
A6256 09
A6257 09
A6258 09
A6259 09
A6260 09
A6261 09
A6262 09
A6266 09
A6402 09
A6403 09
A6404 09
A6410 09
A6446 09
A6501 09
A6502 09
A6504 09
A6505 09
A6506 09
A6507 09
A6508 09
A6510 09
A6511 09
A6513 09
A6530 09
A6531 07
A6531 09
A6532 07
A6532 09
A6533 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
HYDROCOLLD DRG > 48 IN W/O B
HYDROCOLLD DRG <=16 IN W/BDR
HYDROCOLLD DRG >16<=48 W/BDR
HYDROCOLLD DRG FILLER PASTE
HYDROCOLLOID DRG FILLER DRY
HYDROGEL DRG <=16 IN W/O BDR
HYDROGEL DRG >16<=48 W/O BDR
HYDROGEL DRG >48 IN W/O BDR
HYDROGEL DRG <= 16 IN W/BDR
HYDROGEL DRG >16<=48 IN W/B
HYDROGEL DRG > 48 SQ IN W/B
HYDROGEL DRSG GEL FILLER-PER OUNCE
SKIN SEAL PROTECT MOISTURIZR
ABSORPT DRG <=16 SQ IN W/O B
ABSORPT DRG >16 <=48 W/O BDR
ABSORPT DRG > 48 SQ IN W/O B
ABSORPT DRG <=16 SQ IN W/BDR
ABSORPT DRG >16<=48 IN W/BDR
ABSORPT DRG > 48 SQ IN W/BDR
TRANSPARENT FILM <= 16 SQ IN
TRANSPARENT FILM >16<=48 IN
TRANSPARENT FILM > 48 SQ IN
WOUND CLEANSER ANY TYPE/SIZE
WOUND FILLER GEL/PASTE /OZ
WOUND FILLER DRY FORM / GRAM
IMPREG GAUZE NO H20/SAL/YARD
STERILE GAUZE <= 16 SQ IN
STERILE GAUZE>16 <= 48 SQ IN
STERILE GAUZE > 48 SQ IN
STERILE EYE PAD
CONFORM BAND S W>=3ƒ <5ƒ/YD
COMPRES BURNGARMENT BODYSUIT
COMPRES BURNGARMETN CHINSTRP
COMPRES BURN GARMENT GLOVE-WRIST
COMPRS BURN GARMENT GLOVE-ELBOW
COMPRS BURN GARMENT GLOVE-AXILLA
CMPRS BURNGARMENT FOOT-KNEE
COMPRES BURNGARMENT FOOT-THIGH
COMPRES BURN GARMENT LEOTARD
COMPRES BURN GARMENT PANTY
COMPRESS BURN MASK, FACE AND/OR
ELASTIC SUPPORTS, ELASTIC STOCKINGS
GRAD COMP STOCKING BELOW KNEE 30-40M
GRAD COMP STOCKING BELOW KNEE 30-40M
ELASTIC SUPPORTS,ELASTIC STOCKING
ELASTIC SUPPORTS,ELASTIC STOCKINGS
ELASTIC SUPPORTS,ELASTIC STOCKINGS
4
FEE
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
.26
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
32.37
MP
42.58
MP
59.99
46.75
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
Y
Y
1
1
1
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
6
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20140501
20140501
20140501
20140501
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
A6534 09
A6535 09
A6536 09
A6537 09
A6538 09
A6539 09
A6540 09
A6541 09
A6544 09
A6545 09
A6549 09
A6550 09
A7000 09
A7001 09
A7002 09
A7003 09
A7004 09
A7005 09
A7006 09
A7007 09
A7008 09
A7009 09
A7010 09
A7011 09
A7012 09
A7013 09
A7014 09
A7015 09
A7016 09
A7017 07
A7017 09
A7030 09
A7031 09
A7032 09
A7033 09
A7034 09
A7035 09
A7036 09
A7037 09
A7038 09
A7039 09
A7045 09
A7046 09
A7047 09
A7501 09
A7502 09
A7520 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
ELASTIC SUPPORTS,ELASTIC STOCKINGS
ELASTIC SUPPORTS, ELASTIC STOCKINGS
ELASTIC SUPPORTS, ELASTIC STOCKINGS
ELASTIC SUPPORTS, ELASTIC STOCKINGS
ELASTIC SUPPORTS, ELASTIC STOCKINGS
ELASTIC SUPPORTS, ELASTIC STOCKINGS
GRAIDENT COMPRESSION STOCKING
ELASTIC SUPPORTS, ELASTIC STOCKINGS
ELASTIC SUPPORTS,ELASTIC STOCKINGS
GRADIENT COMPRESSION WRAP, NON-ELAST
GRADIENT COMPRESSION STOCKING/SLEEVE
DRESSING SET FOR NPWT PUMP
DISPOSABLE CANISTER FOR PUMP
NONDISPOSABLE PUMP CANISTER
TUBING USED W SUCTION PUMP
NEBULIZER ADMINISTRATION SET
DISPOSABLE NEBULIZER SML VOL
NONDISPOSABLE NEBULIZER SET
SMALL VOL FILTERED NEB ADMIN SET
LG VOL NEBULIZER DISP UNFILLED
DISPOSABLE NEBULIZER PREFILL
NEBULIZER RESERVOIR BOTTLE
DISP CORRUGATED TUBING, 100 FEET
NON-DISP CORRUGATED TUBING, 10 FEET
NEBULIZER WATER COLLECTION DEVICE
DISPOSABLE COMPRESSOR FILTER
COMPRESSOR NONDISPOS FILTER
AEROSOL MASK USED W NEBULIZE
NEBULIZER DOME & MOUTHPIECE
NEBULIZER-NOT USED WITH OXYGEN
NEBULIZER-NOT USED WITH OXYGEN
CPAP FULL FACE MASK
REPLACEMENT FACEMASK INTERFACIAL
REPLACEMENT NASAL CUSHION
REPLACEMENT NASAL PILLOWS
NASAL APPLICATION DEVICE
POS AIRWAY PRESS HEADGEAR
POS AIRWAY PRESS CHINSTRAP
POS AIRWAY PRESSURE TUBING
POS AIRWAY PRESSURE FILTER
CPAP FILTER
REPL EXHALATION PORT FOR PAP
REPL WATER CHAMBER, PAP DEV
ORAL INTERFACE USED WITH RESPIRATORY
TRACHEOSTOMA VALVE W DIAPHRA
REPLACEMENT DIAPHRAGM/FPLATE
TRACH/LARYN TUBE NON-CUFFED
4
FEE
56.26
92.52
49.40
80.13
109.50
MP
MP
MP
MP
MP
MP
20.07
6.13
19.52
2.09
1.76
.98
16.84
6.13
2.91
6.01
27.03
12.89
2.36
MP
.45
2.89
1.20
4.55
8.62
86.19
127.16
47.03
31.22
21.89
90.63
29.13
12.47
31.61
4.15
10.10
13.13
13.14
89.13
.91
10.02
36.57
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
7
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20140501
20140501
20140501
20140501
20140501
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20140101
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
A7521 09
A7522 09
A7524 09
A7525 09
A7526 09
A7527 09
A8000 09
A8001 09
A8002 09
A8003 09
A8004 09
A9274 09
A9284 09
A9900 09
A9999 09
B4034 09
B4035 09
B4036 09
B4081 09
B4082 09
B4083 09
B4088 09
B4100 07
B4100 09
B4102 07
B4103 07
B4104 07
B4104 09
B4149 07
B4149 09
B4150 07
B4150 09
B4152 07
B4152 09
B4153 07
B4153 09
B4154 07
B4154 09
B4155 07
B4155 09
B4157 07
B4157 09
B4158 07
B4159 07
B4160 07
B4161 07
B4161 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
TRACH/LARYNGETOMY TUBE CUFFED
TRACH/LARYN TUBE STAINLESS
TRACHEOSTOMA STENT/STUD/BTTN
TRACHESTOMY MASK, EACH
TRACH TUBE HOLDER
TRACH/LARYN TUBE PLUG/STOP
SOFT PROTECT HELMET PREFAB
HARD PROTECT HELMET PREFAB
SOFT ROTECT HELMET CUSTOM
HARD PROTECT HELMET CUSTOM
SOFT INTERFACE FOR HELMET, REPLACEME
EXTERNAL AMBULATORY INSULIN DELIVERY
SPIROMETER, NON-ELECTRONIC, INCLUDES
MISCELLANEOUS DME SUPPLY ACCESSORY
MISCELLANEOUS DME SUPPLY ACCESSORY
ENTERAL FEEDING SUPPLY KIT;-SYRINGE
ENTERAL FEEDING SUPPLY KIT;- PUMP FE
ENTERAL FEEDING SUPPLY KIT; GRAVITY
NASOGASTRIC TUBING WITH STYLET
NASOGASTRIC TUBING WITHOUT STYLET
STOMACH TUBE - LEVINE TYPE
GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PR
THICKENING AGENT; ORAL
THICKENING AGENT, ORAL
EF ADULT FLUIDS
EF PED FLUID AND ELECTROLYTE
ADDITIVE FOR ENTERAL FORMULA (EG,G,F
ADDITIVE FOR ENTERAL FORMULA (E.G.FI
BF BLENDERIZED FOODS
EF BLENDERIZED FOODS
ORAL FORMULA
ENTERAL FORMULA;CATEGORY I: SEMI-SYN
ORAL FORMULA
ENTERAL FORMULAE; CATEGORY II: INTAC
ORAL FORMULA
ENTERAL FORMULAE; CATEGORY III: HYD
ORAL FORMULA
ENTERAL FORMULAE; CATEGORY IV: DEFI
ORAL FORMULA
ENTERAL FORMULAE; CATEGORY V: MODUL
EFF SPEC METABOLIC INHERITANCE DISEA
EF SPEC METABOLIC INHERITANCE DISEAS
EF PED COMPLETE INTACT NUT
EF PED COMPLETE INTACT NUT
EF PED CALORIC DENSE>/=0.7 KC
EF PED CALORIC DENSE>/=0.7KC
EF,PED,HYDROLYZED/AMINO ACIDS
4
FEE
MP
34.78
59.63
1.00
MP
2.42
94.77
94.77
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
13.34
9.93
1.52
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
Y
Y
Y
Y
Y
Y
Y
Y
2
2
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
1
2
1
1
1
1
2
1
2
1
2
1
2
1
2
1
2
Y
Y
Y
Y
Y
8
AGE
RESTRICTION
1
1
1
00
20
REPORT NO:
RF-0-76D
PAGE:
8
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
B4162 07
B4162 09
B9000 07
B9000 09
B9002 07
B9002 09
B9998 09
C1767 09
C1778 09
E0100 09
E0105 09
E0110 09
E0111 09
E0112 09
E0113 07
E0113 09
E0114 09
E0116 09
E0130 07
E0130 09
E0135 07
E0135 09
E0140 07
E0140 09
E0141 07
E0141 09
E0143 07
E0143 09
E0147 07
E0147 09
E0153 09
E0154 07
E0154 09
E0155 09
E0156 09
E0157 07
E0157 09
E0158 09
E0159 09
E0163 09
E0165 09
E0167 07
E0167 09
E0168 09
E0175 09
E0181 09
E0182 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
EF PED SPECMETABOLIC INHERIT
EF PED SPECMETABOLIC INHERIT
ENTERAL PUMP W/O ALARM
ENTERAL PUMP WITHOUT ALARM
ENTERAL PUMP WITH ALARM
ENTERAL PUMP WITH ALARM
NOC FOR ENTERNAL SUPPLIES
VNS GENERATOR
VNS LEADS
CANES; WOOD
CANE QUAD OR THREE PRONG
CRUTCHES FOREARM ADJ OR FIXED PAIR
CRUTCH FOREARM ADJ OR FIXED EACH
CRUTCHES UNDERARM WOOD ADJ PAIR
CRUTCH UNDERARM EACH WOOD
CRUTCH UNDERARM WOOD ADJ OR FIXED EA
CRUTCHES UNDERARM,OTHER THAN WOOD,PR
CRUTCHES UNDERARM,OTHER THAN WOOD,EA
WALKER RIGID ADJUST/FIXED HT
ADJUSTABLE WALKER - PURCHASE
WALKER, FOLDING
WALKER; FOLDING
WALKER W/TRUNK SUPPORT
WALKER W TRUNK SUPPORT
RIGID WHEELED WALKER ADJ/FIX
WALKER WHEELED, WITHOUT SEAT
FOLDING WALKER, WHEELED, WO SEAT
FOLDING WALKER, WHEELED, WITHOUT SE
WALKER VARIABLE WHEEL RESIST
HEAVY DUTY, MULTIPLE BREAKING SYSTE
PLATFORM ATTACHMENT, FOREARM CRUTCH
PLATFORM ATTACHMENT, WALKER, EACH
PLATFORM ATTACHMENT, WALKER, EACH
WHEEL ATTACHMENT, RIGID PICK-UP WAL
SEAT ATTACHMENT, WALKER
WALKER WITH CRUTCH ATTACHMENT
WALKER WITH CRUTCH ATTACHMENT
LEG EXTENSIONS FOR A WALKER
BRAKE FOR WHEELED WALKER
COMMODE CHAIR, STATIONARY, WITH FIX
COMMODE CHAIR, STATIONARY, WITH DET
COMMODE CHAIR PAIL OR PAN
PAIL OR PAN FOR USE WITH COMMODE CH
HEAVYDUTY/WIDE COMMODE CHAIR
FOOT REST, FOR USE WITH COMMODE CHA
PRESSURE PAD, ALTERNATING WITH PUMP,
PUMP FOR ALTERNATING PRESSURE PAD
4
FEE
MP
MP
88.60
MP
88.60
MP
MP
9,396.95
2,243.79
14.19
33.09
52.27
30.49
24.92
MP
MP
31.79
18.69
4.73
47.30
5.59
55.85
22.29
222.91
MP
MP
8.10
80.99
MP
MP
MP
4.75
47.50
18.07
17.81
5.52
MP
19.67
12.04
48.56
75.05
.89
6.87
MP
37.92
165.04
155.38
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
9
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E0184 09
E0185 09
E0186 09
E0187 09
E0188 09
E0189 09
E0196 09
E0197 09
E0198 09
E0199 09
E0202 07
E0202 09
E0240 09
E0241 09
E0242 09
E0243 09
E0244 09
E0245 09
E0246 09
E0250 07
E0250 09
E0251 07
E0251 09
E0255 07
E0255 09
E0256 07
E0256 09
E0260 07
E0260 09
E0261 07
E0261 09
E0265 07
E0265 09
E0266 07
E0266 09
E0271 07
E0271 09
E0272 07
E0272 09
E0275 09
E0276 09
E0290 07
E0290 09
E0291 07
E0291 09
E0292 07
E0292 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
EGGCRATE TYPE MATTRESS
GEL OR GEL-LIKE PRESSURE PAD FOR MAT
AIR PRESSURE MATTRESS
WATER PRESURE MATTRESS
SYNTHETIC SHEEPSKIN PAD
LAMBSWOOL SHEEPSKIN PAD, ANY SIZE
GEL PRESSURE MATTRESS
AIR PRESSURE PAD FOR MATTRESS
WATER PRESSURE PAD FOR MATTRESS
EGGCRATE TYPE PAD FOR MATTRESS
PHOTOTHERAPY (BILIRUBIN) LIGHT
PHOTOTHERAPY (BILIRUBIN) LIGHT WITH
BATH/SHOWER CHAIR, W OR W/O WHEELS
BATH TUB WALL RAIL, EACH
BATH TUB RAIL, FLOOR BASE
TOILET RAIL, EACH
RAISED TOILET SEAT
TUB STOOL OR BENCH
TRANSFER TUB RAIL ATTACHMENT
HOSPITAL BED,WITH SIDE RAILS, FIXED
HOSPITAL BED, WITH SIDE RAILS, FIXE
HOSPITAL BED,WITH SIDE RAILS,FIXED
HOSPITAL BED, WITH SIDE RAILS, FIXE
HOSPITAL BED,WITH SIDE RAIL,VARIAB
HOSPITAL BED, WITH SIDE RAILS VARIA
HOSP BED, VARIABLE HEIGHT,HI LO WITH
HOSPITAL BED VARI HEIGHT HI LO WITH
HOSP BED, WITH SIDE RAILS, SEMI
HOSPITAL BED, WITH SIDE RAILS, SEMI
HOSPITAL BED SEMI ELECTRIC WITH ANY
HOSPITAL BED SEMI ELECTRIC WITH ANY
HOSPITAL BED,TOTAL ELECTRIC W/S
HOSPITAL BED, TOTAL ELECTRIC WITH S
HOSP BED FULLY ELECT WITHOUT
HOSPITAL BED FULLY ELECTRIC WITHOUT
MATTRESS, ZNNERSPRING
MATTRESS, INNERSPRING
MATTRESS FOAM RUBBER
MATTRESS, FOAM RUBBER
BED PAN, STANDARD, METAL OR PLASTIC
BED PAN, FRACTURE, METAL OR PLASTIC
HOSP BED FIXED HEIGHT WITHOUT SI
HOSPITAL BED FIXED HEIGHT WITHOUT SI
HOSP BED FIXED HEIGHT W/O SIDE RAIL
HOSP BED FIXED HEIGHT WITHO SIDE RAI
HOSP BED VAR HEIGHT HI LO WITHOUT SI
HOSP BED VAR HEIGHT HI LO WITHOUT SI
4
FEE
135.92
189.80
121.78
137.74
20.37
35.97
240.97
164.36
164.36
23.77
30.90
MP
MP
MP
MP
MP
MP
MP
42.37
56.50
MP
46.57
465.72
66.22
573.84
66.22
701.85
108.34
1,083.41
115.32
1,153.15
110.36
1,103.54
108.34
1,083.41
12.96
129.64
13.64
136.33
MP
8.96
62.93
629.37
45.72
457.21
70.76
707.67
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
00
00
20
20
REPORT NO:
RF-0-76D
PAGE:
10
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E0293 07
E0293 09
E0294 07
E0294 09
E0295 07
E0295 09
E0296 07
E0296 09
E0297 07
E0297 09
E0301 07
E0301 09
E0302 07
E0302 09
E0303 07
E0303 09
E0304 07
E0304 09
E0305 07
E0305 09
E0310 07
E0310 09
E0325 09
E0326 09
E0328 09
E0329 09
E0370 09
E0424 07
E0430 07
E0430 09
E0431 07
E0433 09
E0439 07
E0443 09
E0444 09
E0445 07
E0445 09
E0450 07
E0450 09
E0463 07
E0463 09
E0464 07
E0464 09
E0470 07
E0470 09
E0471 07
E0471 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
HOSP BED VAR HEIGHT HI LO WITHOUT SI
HOSP BED VAR HEI HI LO WITHOUT SIDE
HOSP BED SEMI ELEC W/O SIDERAIL
HOSP BED SEMI ELEC WITHOUT SIDE RAIL
HOSP BED SEMI ELCT W/O SIDERAIL
HOSPIT BED SEMI ELEC WITHOUT SIDE RA
HOSP BED TOTAL ELEC WITHOUT SIDE
HOSPITAL BED TOTAL ELEC WITHOUT SIDE
HOSP BED TOTAL ELEC WITHOUT SIDE
HOSPITAL BED TOTAL ELEC WITHOUT SIDE
HD HOSP BED,350-600 LBS
HD HOSP BED, 350-600 LBS
EX HD HOSP BED>600 LBS
EX HD HOSP BED > 600 LBS
HOSP BED HVY DTY EXTRA WIDE
HOSP BED HVY DTY XTRA WIDE
HOSP BED XTRA HVY DTY X WIDE
HOSP BED XTRA HVY DTY X WIDE
BED SIDE RAILS, HALF LENGHT
BED SIDE RAILS, HALF LENGTH
RAILS BED SIDE FULL LENGTH
BED SIDE RAILS, FULL LENGTH
URINAL, MALE, ANY MATERIAL
URINAL, FEMALE, ANY MATERIAL
HOSPITAL BED, PEDIATRIC, MANUAL, 360
HOSPITAL BED, PEDIATRIC, ELECTRIC OR
AIR PAD ELEVATOR FOR HEEL
STA COMPRESSED GAS SYSTEM, RENTAL
PORTABLE GASEOUS OXYGEN SYSTEM,RENTA
OXYGEN SYSTEM, GASEOUS, PORTABLE, I
PORTABLE GASEOUS OXYGEN SYSTEM
PORTABLE LIQUID OXYGEN SYSTEM,RENTAL
STATIONARY LIQUID OXYGEN SYS
PORTABLE OXYGEN CONTENTS,GAS,PER UNI
PORT OXYGEN CONTENTS,LIQUID,PER UNIT
OXIMETER DEVICE & MEASURING BLOOD OX
OXIMETER DEVICE & MEASURING BLOOD OX
VENTILATOR AND EQUIPMENT PACKAGE
VENTILATOR AND EQUIPMENT PACKAGE
PRESS SUPP VENT INVASIVE INT
PRESS SUPP VENT INVASIVE INT
PRESS SUPP VENT NONINV INT
PRESS SUPP VENT NONINV INT
NONINVASIVE ASSIST W/O BACKUP
NONINVASIVE ASSIST WO BACKUP
NONINVASIVE ASSIST W BACKUP
NONINVASIVE ASSIST W BACKUP
4
FEE
60.22
602.18
110.02
1,100.18
107.24
1,072.38
138.27
1,382.69
118.46
1,184.59
MP
MP
MP
MP
MP
MP
MP
MP
10.19
MP
13.08
130.79
MP
MP
MP
MP
18.21
191.06
15.64
156.39
15.64
34.80
191.06
MP
70.86
260.01
640.40
577.80
MP
MP
MP
MP
MP
235.65
2,356.94
501.38
5,013.76
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
2
2
2
2
2
2
00
00
20
20
00
20
00
20
00
20
00
00
00
20
20
20
2
2
1
1
2
2
2
2
2
2
2
2
2
2
REPORT NO:
RF-0-76D
PAGE:
11
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20141215
20141215
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E0480 07
E0480 09
E0482 09
E0483 07
E0483 09
E0487 09
E0550 07
E0550 09
E0555 09
E0560 07
E0560 09
E0561 07
E0561 09
E0562 07
E0562 09
E0565 07
E0565 09
E0570 07
E0570 09
E0580 07
E0580 09
E0585 07
E0585 09
E0600 07
E0600 09
E0601 07
E0601 09
E0607 09
E0619 07
E0619 09
E0621 07
E0621 09
E0630 07
E0630 09
E0638 09
E0642 09
E0650 09
E0651 09
E0652 09
E0656 09
E0657 09
E0665 09
E0667 09
E0668 09
E0669 09
E0671 09
E0672 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
PERCUSSOR,ELECTRIC OR PNEUMATIC,H
PERCUSSOR, ELECTRIC OR PNEUMATIC, H
COUGH STIMULATION DEVICE
CHEST COMPRESSION GEN SYSTEM
CHEST COMPRESSION GEN SYSTEM
SPIROMETER, ELECTRONIC, INCLUDES ALL
HUMIDIFIER,DURABLE FOR EXT
HUMIDIFIER, DURABLE FOR EXTENSIVE SU
HUMIDIFIER, DURABLE, GLASS OR AUTOCL
HUMIDIFIER,DURABLE FOR SUPPLEMENTAL
HUMIDIFIER, DURABLE FOR SUPPLEMENTAL
HUMIDIFIER NONHEATED USED W PAP
HUMIDIFIER NONHEATED W PAP
HUMIDIFIER HEATED USED WITH PAP
HUMIDIFIER HEATED USED W PAP
COMPRESSOR (NOT OXYGEN OR IPPB)
COMPRESSOR (NOT OXYGEN OR IPPB)
NEBULIZER,WITH COMPRESSOR EA, DEV
NEBULIZER, WITH COMPRESSOR E.G., DEV
NEBULIZER,DURABLE, GLASS OR AUTOCLAY
NEBULIZER, DURABLE, GLASS OR AUTOCLA
NEBULIZER WITH COMPRESSER AND HEATER
NEBULIZER, WITH COMPRESSOR AND HEATE
SUCTION PUMP,HOME MODEL,PORTABLE
SUCTION PUMP, HOME MODEL, PORTABLE
CONTINUOUS POSITIVE AIRWAY PRESSURE
CONTINUOUS POSITIVE AIRWAY PRESSURE
HOME BLOOD GLUCOSE MONITOR
APNEA MONITOR W RECORDER
APNEA MONITOR WITH RECORDER
PATIENT LIFT SLING OR SEAT
SLING OR SEAT, PATIENT LIFT, CANVAS
PATIENT LIFT,HYDRAULIC, WITH SEAT O
PATIENT LIFT, HYDRAULIC, WITH SEAT O
STANDING FRAME/TABLE SYSTEM, ONE POS
DYNAMIC STANDING FRAME
PNEUMATIC COMPRESSOR, NON-SEGMENTAL
PNEUMATIC COMPRESSOR,SEGMENTAL HOME
PNEUMATIC COMPRESS,SEGMENTAL HOME MO
SEGMENTAL PNEUMATIC APPLIANCE FOR US
SEGMENTAL PNEUMATIC APPLIANCE FOR US
PNEUMATIC APPLIANCE FOR USE WITH PN
PNEUMATIC APPL.USE W/SPC,LEG
PNEUMATIC APPL.USE W/SPC,ARM
SEGMENTQL PNEUMATIC APP, HALF LEG
PRESSURE PNEUM APPL FULL LEG
PRESSURE PNEUM APPL FULL ARM
4
FEE
24.01
358.04
4,455.81
MP
MP
MP
27.39
273.95
MP
11.03
MP
7.21
68.80
19.37
193.68
33.34
333.48
14.45
57.78
14.45
98.50
14.45
257.70
21.67
MP
87.22
872.19
26.48
233.77
1,829.70
MP
MP
85.79
857.94
MP
MP
708.83
903.90
5,217.63
MP
MP
134.83
318.65
434.89
180.41
408.79
317.62
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
8
AGE
RESTRICTION
00
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
00
20
20
REPORT NO:
RF-0-76D
PAGE:
12
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20130201
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20140501
20140501
20140501
20140501
20140501
20140501
20140501
20140501
20140501
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E0673 09
E0705 07
E0705 09
E0747 07
E0747 09
E0748 07
E0748 09
E0760 09
E0766 07
E0770 09
E0776 07
E0776 09
E0779 07
E0779 09
E0781 07
E0781 09
E0783 09
E0784 07
E0784 09
E0785 09
E0786 09
E0791 07
E0791 09
E0840 07
E0840 09
E0849 07
E0849 09
E0850 07
E0850 09
E0855 09
E0860 07
E0860 09
E0870 07
E0870 09
E0880 07
E0880 09
E0890 07
E0890 09
E0900 07
E0900 09
E0910 07
E0910 09
E0920 07
E0920 09
E0930 07
E0930 09
E0935 07
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
PRESSURE PNEUM APPL HALF LEG
TRANSFER BOARD, RENTAL
TRANSFER BOARD
OSTEOGENESIS STIM NONSPINAL NONINV
OSTEOGENESIS STIM,NON-SPINAL,NON-INV
OSTEOGENIC STIMULATOR SPINAL
OSTEOGENIC STIMULATOR SPINAL
OSTOGENESIS STIMULATOR, LOW
ELECTRICAL STIMULATION DEVICE
FUNCTIONAL ELECTRICAL STIMULATOR, TR
IV POLE
IV POLE
AMBULATORY INF PUMP REUSABLE 8HR/MOR
AMBULATORY INF PUMP RESUABLE 8HR/MOR
EXTERNAL AMBULATORY INFUSION PUMP
EXTERNAL AMBULATORY INFUSION P
PROGRAMMABLE INFUSION PUMP
EXT AMB INFUSION PUMP INSULIN
EXT AMB INFUSN PUMP INSULIN
REPLACEMENT IMPL PUMP CATHET
IMPLANTABLE PUMP REPLACEMENT
PARENTERAL INFUSION PUMP STATIONARY
PARENTAL INFUSION PUMP STATIONARY
TRACT FRAME ATTACH HEADBOARD
TRACTION FRAME, ATTACHED TO HEADBOAR
CERVICAL PNEUM TRACT EQUIP
CERVICAL PNEUM TRAC EQUIP
TRACTION ON CERVICAL W/O HEAD HALTER
TRACTION CERVICL W/O HEAD HALTER
CERVICAL TRACTION EQUIPMENT
TRACT EQUIP CERVICAL TRACT
TRACTION OVERDOOR
TRACTION FRAME,ATTACHED TO HEADBOARD
TRACTION FRAME, ATTACHED TO FOOTBOA
TRANCTION STAND FREE STANDING SIMP
TRACTION STAND, FREE STANDING, SIMP
TRACTION FRAME ATTACHED TO FOOTBOAR
TRACTION FRAME, ATTACHED TO FOOTBOAR
TRACTION STAND FREE STANDING SIMP
TRACTION STAND, FREE STANDING, SIMP
TRAPEZE BAR FULL-LENGTH 2 POST
TRAPEZE BAR; FULL-LENGTH, 2 POST
FRACTURE FRAME ATTACHED TO BED IN
FRACTURE FRAME, ATTACHED TO BED, IN
FRACTURE FRAME FREE STANDING INCL
FRACTURE FRAME, FREE STANDING, INCL
CONT PAS MOTION EXERCISE DEV
4
FEE
263.93
3.71
37.13
237.60
MP
236.07
MP
2,173.98
286.86
MP
6.40
MP
170.16
106.24
170.31
MP
6,948.50
485.12
MP
304.61
5,448.40
172.38
MP
MP
MP
31.41
317.21
5.26
MP
22.72
MP
MP
5.83
MP
6.29
62.90
7.10
MP
7.55
75.53
15.80
158.03
23.24
MP
22.88
MP
15.49
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
8
AGE
RESTRICTION
2
2
2
2
2
2
1
2
2
1
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
04
99
04
99
REPORT NO:
RF-0-76D
PAGE:
13
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20140501
20120701
20120701
20120701
20120701
20120701
20140101
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E0940 07
E0940 09
E0941 07
E0941 09
E0942 09
E0944 07
E0944 09
E0945 07
E0945 09
E0946 07
E0946 09
E0947 07
E0947 09
E0948 07
E0948 09
E0950 09
E0951 09
E0952 09
E0955 09
E0956 09
E0957 09
E0958 09
E0959 09
E0960 09
E0961 09
E0966 09
E0967 09
E0968 09
E0969 09
E0970 09
E0971 09
E0973 09
E0974 09
E0978 09
E0980 09
E0981 09
E0982 09
E0984 09
E0985 09
E0986 07
E0986 09
E0988 09
E0990 09
E0992 09
E0994 09
E0995 09
E1002 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
TRAPEZE BAR FREE STANDING COMPLETE
TRAPEZE BAR, FREE STANDING, COMPLETE
GRAVITY ASSISTED TRACTION DEVICE A
GRAVITY ASSISTED TRACTION DEVICE, A
TRACTION,CERVICAL WITH HEAD HALTER
PELVIC BELT/HARNESS/BOOT
PELVIC BELT/HARNESS/BOOT
BELT/HARNESS EXTREMITY
EXTREMITY BELT/HARNESS
FRACTURE FRAME DUAL WITH CROSS BA
FRACTURE, FRAME, DUAL WITH CROSS BA
FRACTURE FRAME ATTACHMENTS FOR COM
FRACTURE FRAME, ATTACHMENTS FOR COM
FRACTURE FRAME ATTACHMENTS FOR COM
FRACTURE FRAME, ATTACHMENTS FOR COM
TRAY
LOOP HEEL, EACH
LOOP TOE, EACH
CUSHIONED HEADREST
W/C LATERAL TRUNK/HIP SUPPOR
W/C MEDIAL THIGH SUPPORT
WHEELCHAIR ATTACHMENT TO CONVERT AN
AMPUTEE ADAPTER (DEVICE USED TO COM
W/C SHOULDER HARNESS/STRAPS
BRAKE EXTENSION, FOR WHEELCHAIR
HOOK ON HEAD REST EXTENSION
WHEELCHAIR HAND RIMS WITH 8 VERTICA
COMMODE SEAT, WHEELCHAIR
NARROWING DEVICE, WHEELCHAIR
NO.2 FOOTPLATES, EXCEPT FOR ELEVATI
ANTI-TIPPING DEVICE WHEELCHAIRS
ADJUSTABLE HEIGHT DETACHABLE ARMS,
"GRADE-AID" DEVICE TO PREVENT ROLL
BELT, SAFETY WITH AIRPLANE BUCKLE,
SAFETY VEST, WHEELCHAIR
SEAT UPHOLSTERY, REPLACEMENT
BACK UPHOLSTERY, REPLACEMENT
ADD PWR TILLER
W/C SEAT LIFT MECHANISM
MAN W/C PUSH-RIM POW ASSIST
MAN W/C PUSH-RIM POW ASSIST
MANUAL WHEELCHAIR ACCESSORY, LEVER-A
ELEVATING LEG REST, EACH
SOLID SEAT INSERT
ARM REST, EACH
CALF REST, EACH
PWR SEAT TILT
4
FEE
24.81
248.87
23.24
MP
9.95
MP
MP
MP
MP
29.64
MP
30.38
MP
29.32
MP
MP
MP
MP
MP
MP
MP
26.96
27.33
56.22
18.38
MP
MP
MP
MP
MP
26.81
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
216.74
72.56
58.81
MP
MP
2,541.76
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
14
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E1003 09
E1004 09
E1005 09
E1006 09
E1007 09
E1008 09
E1009 09
E1011 09
E1014 09
E1015 09
E1016 09
E1017 09
E1018 09
E1020 09
E1028 09
E1029 09
E1035 09
E1036 09
E1038 09
E1050 07
E1050 09
E1060 07
E1060 09
E1070 07
E1070 09
E1083 07
E1083 09
E1084 07
E1084 09
E1085 07
E1085 09
E1086 07
E1086 09
E1087 07
E1087 09
E1088 07
E1088 09
E1089 07
E1089 09
E1090 07
E1090 09
E1092 07
E1092 09
E1093 07
E1093 09
E1100 07
E1100 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
PWR SEAT RECLINE
PWR SEAT RECLINE MECH
PWR SEAT RECLINE
PWR SEAT COMBO W/O SHEAR
PWR SEAT COMBO W/SHEAR
PWR SEAT COMBO PWR SHEAR
ADD MECH LEG ELEVATION
PED WC MODIFY WIDTH ADJUSTM
RECLINING BACK ADD PED W/C
SHOCK ABSORBER FOR MAN W/C
SHOCK ABSORBER FOR POWER W/C
HD SHOCK ABSRBER FOR HD MAN WC
HD SHOCK ABSRBER
RESIDUAL LIMB SUPPORT SYSTEM
W/C MANUAL SWINGAWAY
W/C VENT TRAY FIXED
GERIATRIC CHAIR
MULTI-POSITIONAL PT TRANSFER SYS
TRANSPORT CHAIR
FULLY-RECLINING WHEELCHAIR FIXED F
FULLY-RECLINING WHEELCHAIR, FIXED F
FULLY-RECLINING WHEELCHAIR DETACHA
FULLY-RECLINING WHEELCHAIR, DETACHA
FULLY-RECLINING WHEELCHAIR DETACHAB
FULLY-RECLINING WHEELCHAIR, DETACHAB
HEMI-WHEELCHAIR FIXED FULL LENGTH
HEMI-WHEELCHAIR, FIXED FULL LENGTH
HEMI-WHEELCHAIR DETACHABLE ARMS DE
HEMI-WHEELCHAIR, DETACHABLE ARMS DE
HEMI-WHEELCHAIR FIXED FULL LENGTH
HEMI-WHEELCHAIR, FIXED FULL LENGTH
HEMI-WHEELCHAIR DETACHABLE ARMS DES
HEMI-WHEELCHAIR DETACHABLE ARMS DES
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR
HIGH STRENGTH LIGHTWEIGHT WHEELCHAI
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR
HIGH STRENGTH LIGHTWEIGHT WHEELCHAI
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR
HIGH STRENGTH LIGHTWEIGHT WHEELCHAI
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR
HIGH STRENGTH LIGHTWEIGHT WHEELCHAI
WIDE HEAVY DUTY WHEELCHAIR DETACH
WIDE HEAVY DUTY WHEEL CHAIR, DETACH
WIDE HEAVY DUTY WHEELCHAIR DETACHA
WIDE HEAVY DUTY WHEELCHAIR, DETACHA
SEMI-RECLINING WHEELCHAIR FIXED FU
SEMI-RECLINING WHEELCHAIR, FIXED FU
4
FEE
MP
MP
3,256.98
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
127.63
MP
MP
MP
121.22
60.02
MP
64.55
MP
64.55
MP
46.41
464.11
54.07
540.73
40.78
407.94
49.55
MP
64.16
MP
66.22
MP
60.22
MP
68.23
MP
66.22
MP
55.36
MP
55.23
MP
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
15
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E1110 07
E1110 09
E1130 07
E1130 09
E1140 07
E1140 09
E1150 07
E1150 09
E1160 07
E1160 09
E1161 07
E1161 09
E1170 07
E1170 09
E1171 07
E1171 09
E1172 07
E1172 09
E1180 07
E1180 09
E1190 07
E1190 09
E1195 07
E1195 09
E1200 07
E1200 09
E1220 09
E1221 07
E1221 09
E1222 07
E1222 09
E1223 07
E1223 09
E1224 07
E1224 09
E1225 09
E1226 09
E1227 09
E1228 09
E1231 07
E1231 09
E1232 07
E1232 09
E1233 07
E1233 09
E1234 07
E1234 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
SEMI-RECLINING WHEELCHAIR DETACHABLE
SEMI-RECLINING WHEELCHAIR, DETACHABL
STANDARD WHEELCHAIR FIXED FULL LEN
STANDARD WHEELCHAIR, FIXED FULL LEN
WHEELCHAIR DETACHABLE ARMS DESK O
WHEELCHAIR, DETACHABLE ARMS, DESK O
WHEELCHAIR DETACHABLE ARMS DESK O
WHEELCHAIR, DETACHABLE ARMS, DESK O
WHEELCHAIR FIXED FULL LENGTH ARMS
WHEELCHAIR, FIXED FULL LENGTH ARMS,
MANUAL ADULT WC W TILTINSPAC
MANUAL ADULT W/C W TILTN SPACE
AMPUTEE WHEELCHAIR FIXED FULL LENGTH
AMPUTEE WHEELCHAIR, FIXED FULL LENG
AMPUTEE WHEELCHAIR FIXED FULL LENGTH
AMPUTEE WHEELCHAIR, FIXED FULL LENG
AMPUTEE WHEELCHAIR DETACHABLE ARMS
AMPUTEE WHEELCHAIR, DETACHABLE ARMS
AMPUTEE SHEELCHAIR DETACHABLE ARMS
AMPUTEE WHEELCHAIR, DETACHABLE ARMS
AMPUTEE WHEELCHAIR DETACHABLE ARMS
AMPUTEE WHEELCHAIR, DETACHABLE ARMS
HEAVY DUTY WHEELCHAIR FIXED FULL
HEAVY DUTY WHEELCHAIR, FIXED FULL L
AMPUTEE WHEELCHAIR FIXED FULL LENGTH
AMPUTEE WHEELCHAIR, FIXED FULL LENGT
SPECIAL SIZED/CONSTRUCTED WHEELCHAIR
WHEELCHAIR WITH FIXED ARM FOOTREST
WHEELCHAIR WITH FIXED ARM, FOOTREST
WHEELCHAIR WIH FIXED ARM ELEVATING
WHEELCHAIR WITH FIXED ARM, ELEVATIN
WHEELCHAIR WITH DETACHABLE ARMS FO
WHEELCHAIR WITH DETACHABLE ARMS, FO
WHEELCHAIR WITH DETACHABLE ARMS EL
WHEELCHAIR WITH DETACHABLE ARMS, EL
SEMI-RECLINING BACK FOR CUSTOMIZED
FULL RECLINING BACK FOR CUSTOMIZED
SPECIAL HEIGHT ARMS FOR WHEELCHAIR
SPECIAL BACK HEIGHT FOR WHEELCHAIR
RIGID PED W/C TILT-IN-SPACE
RIGID PED W/C TILT-IN-SPACE
FOLDING PED WC TILT-IN-SPACE
FOLDING PED W/C TILT-IN-SPACE
RIG PED WC TLTNSPC W/O SEAT
RIG PED W/C TLTNSPC W/O SEAT
FLD PED WC TLTNSPC W/O SEAT
FLD PED W/C TLTNSPACE W/O SEAT
4
FEE
50.93
MP
30.90
220.71
36.42
364.17
40.05
400.59
33.11
331.07
MP
MP
46.92
639.26
66.22
MP
66.22
MP
66.22
725.33
66.22
855.20
66.22
MP
66.22
MP
MP
23.81
237.99
36.44
364.42
39.84
MP
50.15
MP
MP
MP
MP
MP
MP
MP
MP
1,321.51
MP
MP
MP
1,192.06
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
16
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E1235 07
E1235 09
E1236 07
E1236 09
E1237 07
E1237 09
E1238 07
E1240 07
E1240 09
E1250 07
E1250 09
E1260 07
E1260 09
E1270 07
E1270 09
E1280 07
E1280 09
E1285 07
E1285 09
E1290 07
E1290 09
E1295 07
E1295 09
E1296 07
E1296 09
E1297 09
E1298 09
E1355 07
E1355 09
E1358 09
E1390 07
E1390 09
E1399 07
E1399 09
E1510 09
E1520 09
E1530 09
E1540 09
E1550 09
E1560 09
E1575 09
E1580 09
E1590 09
E1592 09
E1594 09
E1600 09
E1610 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
RIGID PED WC ADJUSTABLE
RIGID PED W/C ADJUSTABLE
FOLDING PED WC ADJUSTABLE
FOLDING PED W/C ADJUSTABLE
RGD PED WC ADJSTABL W/O SEAT
RIGID PED WC ADJUSTABLE W/O SEAT
FLD PED WC ADJUSTABLE W/O SEATING
LIGHTWEIGHT WHEELCHAIR DETACHABLE
LIGHTWEIGHT WHEELCHAIR, DETACHABLE
LIGHTWEIGHT WHEELCHAIR FIXED FULL L
LIGHTWEIGHT WHEELCHAIR, FIXED FULL L
LIGHTWEIGHT WHEELCHAIR DETACHABLE A
LIGHTWEIGHT WHEELCHAIR, DETACHABLE A
LIGHTWEIGHT WHEELCHAIR FIXED FULL
LIGHTWEIGHT WHEELCHAIR, FIXED FULL
HEVY DUTY WHEELCHAIR DETACHABLE ARM
HEAVY DUTY WHEELCHAIR, DETACHABLE AR
HEAVY DUTY WHEELCHAIR FIXED FULL LE
HEAVY DUTY WHEELCHAIR, FIXED FULL LE
HEAVY DUTY WHEELCHAIR DETACHABLE ARM
HEAVY DUTY WHEELCHAIR, DETACHABLE AR
HEAVY DUTY WHEELCHAIR FIXED FULL LE
HEAVY DUTY WHEELCHAIR, FIXED FULL LE
WHEELCHAIR SPECIAL SEAT HEIG
SPECIAL WHEELCHAIR SEAT HEIGHT FROM
SPECIAL WHEELCHAIR SEAT DEPTH, BY U
SPECIAL WHEELCHAIR SEAT DEPTH AND/O
STANDY/RACK
STAND/RACK
OXYGEN ACCESSORY, DC POWER ADAPTER F
OXYGEN CONCENTRATOR EQUIVALENT TO
OXYGEN CONCENTRATOR, EQUIVALENT TO
DURABLE MEDICAL EQUIPMENT,NOR OTHER
DURABLE MEDICAL EQUIPMENT, NOT OTHER
KIDNEY, DIALYSATE DELIVERY SYST. KID
HEPARIN INFUSION PUMP FOR DIALYSIS
AIR BUBBLE DETECTOR FOR DIALYSIS
PRESSURE ALARM FOR DIALYSIS
BATH CONDUCTIVITY METER FOR DIALYSI
BLOOD LEAK DETECTOR FOR DIALYSIS
TRANSDUCER PROTECTORS/FLUID BARRIER
UNIPUNCTURE CONTROL SYSTEM FOR DIALY
HEMODIALYSIS MACHINE
AUTOMATIC INTERMITTENT PERITIONEAL
CYCLER DIALYSIS MACHINE
DELIVERY AND/OR INSTALLATION CHARGES
REVERSE OSMOSIS WATER PURIFICATION
4
FEE
MP
1,147.86
MP
MP
MP
1,021.56
MP
51.61
MP
44.79
MP
54.94
MP
45.51
MP
65.76
MP
60.42
MP
62.69
MP
60.85
MP
MP
MP
MP
MP
4.60
MP
MP
132.42
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
2
2
1
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
17
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E1615 09
E1620 09
E1625 09
E1630 09
E1632 09
E1635 09
E1636 09
E1699 09
E1800 07
E1802 07
E1805 07
E1810 07
E1815 07
E1825 07
E1830 07
E1840 07
E1902 09
E2201 09
E2202 09
E2203 09
E2204 09
E2205 09
E2206 09
E2207 09
E2208 07
E2208 09
E2209 09
E2210 09
E2211 09
E2212 09
E2213 09
E2214 09
E2215 09
E2216 09
E2217 09
E2218 09
E2219 09
E2220 09
E2221 09
E2222 09
E2224 09
E2225 09
E2226 09
E2230 09
E2231 09
E2295 09
E2310 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
DEIONIZER WATER PURIFICATION SYSTEM
BLOOD PUMP FOR DIALYSIS
WATER SOFTENING SYSTEM
RECIPROCATING PERITONEAL DIALYSIS SY
WEARABLE ARTIFICAL KIDNEY
COMPACT (PORTABLE) TRAVEL HEMODIALYZ
SORBENT CARTRIDGES, PER CASE
DIALYSIS EQUIPMENT, UNSPECIFIED, BY
ADJUST ELBOW EXT/FLEX DEVICE
ADJST FOREARM PRO/SUP DEVICE
ADJUST WRIST EXT/FLEX DEVICE
ADJUST KNEE EXT/FLEX DEVICE
ADJUST ANKLE EXT/FLEX DEVICE
ADJUST FINGER EXT/FLEX DEVC
ADJUST TOE EXT/FLEX DEVICE
ADJ SHOULDER EXT/FLEX DEVICE
AAC NON-ELECTRONIC BOARD
MAN W/CH ACC SEAT W>=20ƒ<24ƒ
SEAT WIDTH 24-27 IN
FRAME DEPTH LESS THAN 22 IN
FRAME DEPTH 22 TO 25 IN
MANUAL WC ACCESSORY, HANDRIM
COMPLETE WHEEL LOCK ASSEMBLY
CRUTCH AND CANE HOLDER
CYLINDER TANK CARRIER
CYLINDER TANK CARRIER
ARM TROUGH EACH
WHEELCHAIR BEARINGS
PNEUMATIC PROPULSION TIRE
PNEUMATIC PROP TIRE TUBE
PNEUMATIC PROP TIRE INSERT
PNEUMATIC CASTER TIRE EACH
PNEUMATIC CASTER TIRE TUBE
FOAM FILLED PROPULSION TIRE
FOAM FILLED CASTER TIRE EACH
FOAM PROPULSION TIRE EACH
FOAM CASTER TIRE ANY SIZE EACH
SOLID PROPULSION TIRE EACH
SOLID CASTER TIRE EACH
SOLID CASTER INTEGRATED WHEEL
PROPULSION WHEEL EXCLUDES TIRE
CATER WHEEL EXCLUDES TIRE
CASTER FORK REPLACEMENT ONLY
MANUAL WHEELCHAIR ACCESSORY, MANUAL
MANUAL WHEELCHAIR ACCESSORY, SOLID S
MANUAL WHEELCHAIR ACCESSORY, FOR PED
ELECTRO CONNECT BTW CONTROL
4
FEE
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
296.04
MP
20.18
25.13
MP
7.83
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Y
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
18
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20130401
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E2311 09
E2321 09
E2322 09
E2323 09
E2324 09
E2325 09
E2326 09
E2327 09
E2328 09
E2329 09
E2330 09
E2340 09
E2341 09
E2342 09
E2343 09
E2351 09
E2358 09
E2359 09
E2360 09
E2361 09
E2362 09
E2363 09
E2364 09
E2365 09
E2366 09
E2367 09
E2368 09
E2369 09
E2370 09
E2373 09
E2374 09
E2375 09
E2376 09
E2377 09
E2381 09
E2382 09
E2383 09
E2384 09
E2385 09
E2386 09
E2387 09
E2388 09
E2389 09
E2390 09
E2391 09
E2392 09
E2394 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
ELECTRO CONNECT BTW 2 SYS
HAND INTERFACE JOYSTICK
MULT MECH SWITCHES
SPECIAL JOYSTICK HANDLE
CHIN CUP INTERFACE
SIP AND PUFF INTERFACE
BREATH TUBE KIT
HEAD CONTROL INTERFACE MECH
HEAD/EXTREMITY CONTROL INTER
HEAD CONTROL NONPROPORTIONAL
HEAD CONTROL PROXIMITY SWITC
W/C WDTH 20-23 IN SEAT FRAME
W/C WDTH 24-27 IN SEAT FRAME
W/C DPTH 20-21 IN SEAT FRAME
W/C DPTH 22-25 IN SEAT FRAME
ELECTRONIC SGD INTERFACE
POWER WHEELCHAIR ACCESSORY, GROUP 34
POWER WHEELCHAIR ACCESSORY, GROUP 34
W/C BATTERY 22NF N/SEALED LEAD ACID
W/C BATTERY 22NF SEALED LEAD ACID
W/C BATTERY GP24 N/SEALED LEAD ACID
W/C BATTERY-GP24 SEALED LEAD ACID
W/C BATTERY U1 NONSEALED LEAD ACID
W/C BATTERY-U1 SEALED LEAD ACID
BATTERY CHARGER, SINGLE MODE
BATTERY CHARGER, DUAL MODE
POWER WC MOTOR REPLACEMENT
PWR WC GEAR BOX REPLACEMENT
PWR WC MOTOR/GEAR BOX COMBO
POWER WHEELCHAIR ACCESSORY, HAND OR
POWER WHEELCHAIR ACCESSORY, HAND OR
POWER WHEELCHAIR ACCESSORY, NON-EXPA
POWER WHEELCHAIR ACCESSORY, EXPANDAB
POWER WHEELCHAIR ACCESSORY, EXPANDAB
POWER WHEELCHAIR ACCESSORY, PNEUMATI
POWER WHEELCHAIR ACCESSORY, TUBE FOR
POWER WHEELCHAIR ACCESSORY, INSERT F
POWER WHEELCHAIR ACCESSORY, PNEUMATI
POWER WHEELCHAIR ACCESSORY, TUBE FOR
POWER WHEELCHAIR ACCESSORY, FOAM FIL
POWER WHEELCHAIR ACCESSORY, FOAM FIL
POWER WHEELCHAIR ACCESSORY, FOAM DRI
POWER WHEELCHAIR ACCESSORY, FOAM CAS
POWER WHEELCHAIR ACCESSORY, SOLID (R
POWER WHEELCHAIR ACCESSORY, SOLID (R
POWER WHEELCHAIR ACCESSORY, SOLID (R
POWER WHEELCHAIR ACCESSORY, DRIVE WH
4
FEE
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
276.87
MP
MP
MP
126.08
MP
MP
MP
MP
MP
MP
MP
MP
319.22
278.06
496.14
MP
104.66
529.33
829.49
300.16
47.07
12.83
93.85
50.00
30.59
93.01
41.71
31.14
16.91
26.44
12.67
MP
MP
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
19
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
E2395 09
E2396 09
E2402 07
E2506 09
E2508 09
E2510 09
E2512 09
E2599 09
E2601 09
E2602 09
E2603 09
E2604 09
E2605 09
E2606 09
E2607 09
E2608 09
E2609 09
E2611 09
E2612 09
E2613 09
E2614 09
E2615 09
E2616 09
E2617 09
E2619 09
E2620 09
E2621 09
E2622 09
E2623 09
E2624 09
E2625 09
E2626 09
E2627 09
E2628 09
E2629 09
E2630 09
E2631 09
E2632 09
E2633 09
E8000 09
J7300 09
J7301 09
J7302 09
J7307 09
K0001 07
K0001 09
K0002 07
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
POWER WHEELCHAIR ACCESSORY, CASTER W
POWER WHEELCHAIR ACCESSORY, CASTER F
NEGATIVE PRESSURE WOUND THERAPY PUMP
SGD PREREC MSG > 40 MIN
SGD SPELLING PHYS CONTACT
SGD W MULTI METHODS MSG/ACCS
SGD ACCESSORY, MOUNTING SYS
ACCESSORY FOR SGD NOC
GEN W/C CUSHION WDTH < 22 IN
GEN W/C CUSHION WDTH >=22 IN
SKIN PROTECT WC CUS WD <22IN
SKIN PROTECT WC CUS WD>=22IN
POSITION WC CUSH WDTH <22 IN
POSITION WC CUSH WDTH>=22 IN
SKIN PRO/POS WC CUS WD <22IN
SKIN PRO/POS WC CUS WD>=22IN
SIGNATURE 2000 SEAT
GEN USE BACK CUSH WDTH <22IN
GEN USE BACK CUSH WDTH>=22IN
POSITION BACK CUSH WD <22IN
POSITION BACK CUSH WD>=22IN
POS BACK POST/LAT WDTH <22IN
POS BACK POST/LAT WDTH>=22IN
SIGNATURE 2000 BACK
REPLACE COVER W/C SEAT CUSH
WC PLANAR BACK CUSH WD <22IN
WC PLANAR BACK CUSH WD>=22IN
SKIN PROTECTION WHEELCHAIR SEAT CUSH
SKIN PROTECTION WHEELCHAIR SEAT CUSH
SKIN PROTECTION AND POSITIONING WHEE
SKIN PROTECTION AND POSITIONING WHEE
WHEELCHAIR ACCESSORY, SHOULDER ELBOW
WHEELCHAIR ACCESSORY, SHOULDER ELBOW
WHEELCHAIR ACCESSORY, SHOULDER ELBOW
WHEELCHAIR ACCESSORY, SHOULDER ELBOW
WHEELCHAIR ACCESSORY, SHOULDER ELBOW
WHEELCHAIR ACCESSORY, ADDITION TO MO
WHEELCHAIR ACCESSORY, ADDITION TO MO
WHEELCHAIR ACCESSORY, ADDITION TO MO
POSTERIOR GAIT TRAINER
INTRAUTERINE COPPER CONTRACEPTIVE
LEVONORGESTREL-RELEASING INTRAUTERIN
MIRENA-LEV-REL INTRA CONT SYS, 52MG
ETONOGESTREL (CONTRACEPTIVE) IMPLANT
STANDARD WHEELCHAIR
STANDARD WHEELCHAIR
STANDARD HEMI (LOW SEAT) WHEELCHAIR
4
FEE
MP
41.09
1,256.24
1,635.49
2,529.01
MP
MP
MP
54.79
100.04
137.84
195.13
198.80
269.49
182.68
218.76
MP
193.03
261.13
242.90
336.14
279.52
376.10
MP
31.71
355.19
338.47
202.01
257.05
203.66
257.83
382.27
609.98
540.62
684.14
478.42
191.38
116.85
98.19
MP
739.00
650.32
810.51
771.52
30.90
220.71
48.23
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
10
10
10
Y
Y
Y
2
2
2
REPORT NO:
RF-0-76D
PAGE:
20
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
60
60
60
60
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20150101
20140901
20150101
20150101
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
K0002 09
K0003 07
K0003 09
K0004 07
K0004 09
K0005 07
K0005 09
K0006 07
K0006 09
K0007 07
K0007 09
K0009 07
K0009 09
K0010 07
K0010 09
K0011 07
K0011 09
K0014 07
K0014 09
K0015 09
K0017 09
K0018 09
K0019 09
K0020 09
K0037 09
K0038 09
K0039 09
K0040 09
K0041 09
K0042 09
K0043 09
K0044 09
K0045 09
K0046 09
K0047 09
K0050 09
K0051 09
K0052 09
K0053 09
K0056 09
K0065 09
K0069 09
K0070 09
K0071 09
K0072 09
K0073 09
K0077 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
STANDARD HEMI (LOW SEAT) WHEELCHAIR
LIGHTWEIGHT WHEELCHAIR
LIGHTWEIGHT WHEELCHAIR
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR
HIGH STRENGTH, LIGHTWEIGHT WHEELCHAI
ULTRALIGHTWEIGHT WHEELCHAIR
ULTRALIGHTWEIGHT WHEELCHAIR
HEAVY DUTY WHEELCHAIR
HEAVY DUTY WHEELCHAIR
EXTRA HEAVY DUTY WHEELCHAIR
EXTRA HEAVY DUTY WHEELCHAIR
OTHER MANUAL WHEELCHAIR/BASE
OTHER MANUAL WHEELCHAIR/BASE
STANDARD-WEIGHT FRAME MOTORIZED/PO
STANDARD - WEIGHT FRAME MOTORIZED/PO
STANDARD-WEIGHT FRAME MOTORIZED/PO
STANDARD - WEIGHT FRAME MOTORIZED/PO
OTHER MOTORIZED/POWER WHEELCHAIR BAS
OTHER MOTORIZED/POWER WHEELCHAIR BAS
DETACHABLE, NON-ADJUSTABLE HEIGHT AR
DETACHABLE, ADJUSTABLE HEIGHT ARMRES
DETACHABLE, ADJUSTABLE HEIGHT ARMRES
ARM PAD, EACH
FIXED, ADJUSTABLE HEIGHT ARMREST, PA
HIGH MOUNT FLIP-UP FOOTREST, EACH
LEG STRAP, EACH
LEG STRAP, H STYLE, EACH
ADJUSTABLE ANGLE FOOTPLATE, EACH
LARGE SIZE FOOTPLATE, EACH
STANDARD SIZE FOOTPLATE, EACH
FOOTREST, LOWER EXTENSION TUBE, EACH
FOOTREST, UPPER HANGER BRACKET, EACH
FOOTREST, COMPLETE ASSEMBLY
ELEVATING LEGREST, LOWER EXTENSION T
ELEVATING LEGREST, UPPER HANGER BRAC
RATCHET ASSEMBLY
CAM RELEASE ASSEMBLY, FOOTREST OR LE
SWINGAWAY, DETACHABLE FOOTRESTS, EAC
ELEVATING FOOTRESTS, ARTICULATING (T
SEAT HEIGHT < 17" OR < OR EQUAL TO 2
SPOKE PROTECTORS
REAR WHEEL ASSEMBLY, COMPLETE, WITH
REAR WHEEL ASSEMBLY, COMPLETE, WITH
FRONT CASTER ASSEMBLY, COMPLETE, WIT
FRONT CASTER ASSEMBLY, COMPLETE, WIT
CASTER PIN LOCK,EACH
FRONT CASTER ASSEMBLY, COMPLETE, WIT
4
FEE
482.34
52.81
528.13
66.22
669.58
66.22
1,527.98
62.84
628.37
66.22
1,047.78
66.22
MP
66.22
MP
66.22
MP
66.22
MP
122.41
34.44
19.23
11.61
31.30
27.58
16.34
36.30
50.31
35.65
23.08
13.15
11.22
38.14
13.15
51.52
21.89
35.44
62.28
68.72
64.07
29.95
67.30
123.40
73.59
44.30
23.44
39.64
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
21
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
K0098 09
K0105 09
K0108 09
K0195 09
K0283 07
K0455 09
K0552 09
K0606 07
K0672 09
K0730 07
K0733 09
K0738 07
K0738 09
K0739 07
K0739 09
K0740 09
K0741 07
K0742 09
K0743 09
K0744 09
K0745 09
K0746 09
K0813 09
K0814 07
K0814 09
K0815 09
K0816 09
K0820 09
K0821 09
K0822 09
K0823 07
K0823 09
K0824 09
K0825 07
K0825 09
K0826 09
K0827 09
K0828 09
K0829 09
K0830 09
K0831 09
K0835 09
K0836 09
K0837 09
K0838 09
K0839 09
K0840 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
DRIVE BELT FOR POWER WHEELCHAIR
IV HANGER
WHEELCHAIR ACCESSORIES
ELEVATING LEG RESTS, PAIR
POWERWHEELCHAIR, GROUP 2 STANDARD
PUMP UNINTERRUPTED INFUSION
SUPPLY/EXT INF PUMP SYR TYPE
AED GARMENT W ELEC ANALYSIS
ADDITION TO LOWER EXTREMITY ORTHOSIS
CONTROL DOSE INHALER DRUG DELIVERY
POWER WHEELCHAIR ACCESSORY, 12 TO 24
PORTABLE GAS OXYGEN SYSTEM, RENTAL
PORTABLE GASEOUS OXYGEN SYSTEM
REPAIR FOR DME-PARTS USE RP MODIFIER
REPAIR FOR DME - PARTS USE RP MODIFI
REPAIR OR NONROUTINE SERVICE FOR OXY
PORTABLE GASEOUS OXYGEN SYSTEM, RENT
PORTABLE OXYGEN CONTENTS, GASEOUS, 1
SUCTION PUMP, HOME MODEL, PORTABLE,
ABSORPTIVE WOUND DRESSING FOR USE WI
ABSORPTIVE WOUND DRESSING FOR USE WI
ABSORPTIVE WOUND DRESSING FOR USE WI
POWER WHEELCHAIR, GROUP 1 STANDARD,
POWER WHEELCHAIR, GROUP 1 STANDARD
POWER WHEELCHAIR, GROUP 1 STANDARD,
POWER WHEELCHAIR, GROUP 1 STANDARD,
POWER WHEELCHAIR, GROUP 1 STANDARD,
POWER WHEELCHAIR, GROUP 2 STANDARD,
POWER WHEELCHAIR, GROUP 2 STANDARD,
POWER WHEELCHAIR, GROUP 2 STANDARD,
POWER WHEELCHAIR, GROUP 2 STANDARD
POWER WHEELCHAIR, GROUP 2 STANDARD,
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY
POWER WHEELCHAIR, GROUP 2 VERY HEAVY
POWER WHEELCHAIR, GROUP 2 VERY HEAVY
POWER WHEELCHAIR, GROUP 2 EXTRA HEAV
POWER WHEELCHAIR, GROUP 2 EXTRA HEAV
POWER WHEELCHAIR, GROUP 2 STANDARD,
POWER WHEELCHAIR, GROUP 2 STANDARD,
POWER WHEELCHAIR, GROUP 2 STANDARD,
POWER WHEELCHAIR, GROUP 2 STANDARD,
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY
POWER WHEELCHAIR, GROUP 2 VERY HEAVY
POWER WHEELCHAIR, GROUP 2 EXTRA HEAV
4
FEE
18.33
66.98
MP
141.96
MP
1,946.34
MP
2,518.27
63.56
166.02
18.66
31.91
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
305.61
MP
MP
MP
MP
MP
MP
367.85
MP
MP
434.41
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
00
00
20
20
00
00
20
20
REPORT NO:
RF-0-76D
PAGE:
22
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
Y
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20081001
20120701
20120701
20120701
20120701
20130401
20120701
20130401
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
K0841 09
K0842 09
K0843 09
K0848 09
K0849 09
K0850 09
K0851 09
K0852 09
K0853 09
K0854 09
K0855 09
K0856 09
K0857 09
K0858 09
K0859 09
K0860 09
K0861 09
K0862 09
K0863 09
K0864 09
K0868 09
K0869 09
K0870 09
K0871 09
K0877 09
K0878 09
K0879 09
K0880 09
K0884 09
K0885 09
K0886 09
K0890 09
K0891 09
K0898 09
K0899 09
L0113 09
L0120 09
L0130 09
L0140 09
L0150 09
L0160 09
L0170 09
L0172 09
L0174 09
L0180 09
L0190 09
L0200 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
POWER WHEELCHAIR, GROUP 2 STANDARD,
POWER WHEELCHAIR, GROUP 2 STANDARD,
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY
POWER WHEELCHAIR, GROUP 3 STANDARD,
POWER WHEELCHAIR, GROUP 3 STANDARD,
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY
POWER WHEELCHAIR, GROUP 3 VERY HEAVY
POWER WHEELCHAIR, GROUP 3 VERY HEAVY
POWER WHEELCHAIR, GROUP 3 EXTRA HEAV
POWER WHEELCHAIR, GROUP 3 EXTRA HEAV
POWER WHEELCHAIR, GROUP 3 STANDARD,
POWER WHEELCHAIR, GROUP 3 STANDARD,
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY
POWER WHEELCHAIR, GROUP 3 VERY HEAVY
POWER WHEELCHAIR, GROUP 3 STANDARD,
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY
POWER WHEELCHAIR, GROUP 3 VERY HEAVY
POWER WHEELCHAIR, GROUP 3 EXTRA HEAV
POWER WHEELCHAIR, GROUP 4 STANDARD,
POWER WHEELCHAIR, GROUP 4 STANDARD,
POWER WHEELCHAIR, GROUP 4 HEAVY DUTY
POWER WHEELCHAIR, GROUP 4 VERY HEAVY
POWER WHEELCHAIR, GROUP 4 STANDARD,
POWER WHEELCHAIR, GROUP 4 STANDARD,
POWER WHEELCHAIR, GROUP 4 HEAVY DUTY
POWER WHEELCHAIR, GROUP 4 VERY HEAVY
POWER WHEELCHAIR, GROUP 4 STANDARD,
POWER WHEELCHAIR, GROUP 4 STANDARD,
POWER WHEELCHAIR, GROUP 4 HEAVY DUTY
POWER WHEELCHAIR, GROUP 5 PEDIATRIC,
POWER WHEELCHAIR, GROUP 5 PEDIATRIC,
POWER WHEELCHAIR, NOT OTHERWISE CLAS
POWER MOBILITY DEVICE, NOT CODED BY
CRANIAL CERVICAL ORTHOSIS, TORTICOLL
CERVICAL, FLEXIBLE, NON-ADJUSTABLE,
CERVICAL, FLEXIBLE, THERMOPLASTIC CO
CERVICAL, SEMI-RIGID, ADJUSTABLE (PL
CERVICAL, SEMI-RIGID, ADJUSTABLE MOL
CERVICAL, SEMI-RIGID, WIRE FRAME OCC
CERVICAL, COLLAR, MOLDED TO PATIENT
CERVICAL, COLLAR, SEMI-RIGID THERMOP
CERVICAL, COLLAR, SEMI-RIGID, THERMO
NECK BR FORRESTER - NON SWIVEL POSTS
CERVICAL, MULTIPLE POST COLLAR, OCCI
CERVICAL, MULTIPLE POST COLLAR, OCCI
4
FEE
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
MP
16.54
101.78
40.74
67.41
130.27
426.70
87.91
171.37
256.77
332.51
371.53
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7
MCARE
EXEMPT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
23
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L0220 09
L0450 09
L0455 09
L0457 09
L0460 09
L0464 09
L0467 09
L0469 09
L0472 09
L0482 09
L0484 09
L0486 09
L0621 09
L0622 09
L0625 09
L0627 09
L0631 09
L0633 09
L0639 09
L0641 09
L0642 09
L0643 09
L0648 09
L0649 09
L0650 09
L0651 09
L0700 09
L0710 09
L0810 09
L0820 09
L0830 09
L0970 09
L0972 09
L0974 09
L0976 09
L0978 09
L0980 09
L0982 09
L0984 09
L0999 09
L1000 09
L1001 09
L1010 09
L1020 09
L1025 09
L1030 09
L1040 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
THORACIC, RIB BELT, CUSTOM FABRICATE
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPO
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPO
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPO
TLSO, TRIPLANAR CONTROL, MODULAR SEG
TLSO 4MOD SACRO-SCAP PRE
TLSO, SAGITTAL CONTROL, RIGID POSTER
TLSO, SAGITTAL-CORONAL CONTROL, RIGI
TLSO RIGID FRAME HYPEREX PRE
TLSO RIGID LINED CUSTOM FAB
TLSO RIGID PLASTIC CUST FAB
TLSO RIGID LINED CUST FAB TWO
SACROILIAC ORTHOSIS, FLEXIBLE, PROVI
SIO FLEX PELVISACRAL CUSTOM
LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES
LUMBAR ORTHOSIS, SAGITTAL CONTROL, W
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CON
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-COR
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-COR
LUMBAR ORTHOSIS, SAGITTAL CONTROL, W
LUMBAR ORTHOSIS, SAGITTAL CONTROL, W
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CON
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CON
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-COR
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-COR
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-COR
CERVICAL-THORACIC-LUMBAR-SACRAL-ORTH
CTLSO, ANTERIOR-POSTERIOR-LATERAL-CO
HALO PROCEDURES, CERVICAL HALO INCOR
HALO PROCEDURES, CERVICAL HALO INCOR
SPINAL BR MILW SCOL BR W/HALO ATTACH
TLSO, CORSET FRONT
LSO, CORSET FRONT
TLSO, FULL CORSET
LSO, FULL CORSET
AXILLARY CRUTCH EXTENSION
PERONEAL STRAPS, PREFABRICATED, OFFSTOCKING SUPPORTER GRIPS, PREFABRICA
PROTECTIVE BODY SOCK, PREFABRICATED
ADD TO SPINAL ORTHOSIS NOS
CERVICAL-THORACIC-LUMBAR-SACRAL (CTL
CERVICAL THORACIC LUMBAR SACRAL ORTH
ADDITIONS TO CERVICAL-THORACIC-LUMBA
ADDITIONS TO CTLSO OR SCOLIOSIS ORTH
ADDITION TO CTLSO/SCOLIOSIS ORTHO,KY
ADDITIONS TO CTLSO OR SCOLIOSIS ORTH
ADDITIONS TO CTLSO OR SCOLIOSIS ORTH
4
FEE
101.86
108.41
284.96
845.12
673.29
996.97
327.14
378.75
277.61
967.36
1,108.61
1,196.26
62.31
161.16
36.95
275.70
688.54
192.33
814.86
64.05
337.75
133.06
843.52
235.62
998.24
998.24
1,280.15
1,379.04
1,708.47
1,441.19
2,309.12
90.69
82.93
125.38
117.40
122.99
14.52
13.53
37.87
882.83
1,376.93
MP
49.32
68.35
77.79
52.92
55.32
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
24
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20140101
20140101
20120701
20120701
20140101
20140101
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20140101
20140101
20140101
20140101
20140101
20140101
20140101
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L1050 09
L1060 09
L1070 09
L1080 09
L1090 09
L1100 09
L1110 09
L1120 09
L1200 09
L1210 09
L1220 09
L1230 09
L1240 09
L1250 09
L1260 09
L1270 09
L1280 09
L1290 09
L1300 09
L1310 09
L1499 09
L1600 09
L1610 09
L1620 09
L1630 09
L1640 09
L1650 09
L1660 09
L1680 09
L1685 09
L1686 09
L1690 09
L1700 09
L1710 09
L1720 09
L1730 09
L1755 09
L1810 09
L1812 09
L1820 09
L1830 09
L1831 09
L1832 09
L1833 09
L1834 09
L1840 09
L1843 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
ADDITIONS TO CTLSO OR SCOLIOSIS ORTH
ADDITIONS TO CTLSO OR SCOLIOSIS ORTH
ADDITIONS TO CTLSO OR SCOLIOSIS ORTH
ADDITIONS TO CTLSO OR SCOLIOSIS ORTH
ADDITIONS TO CTLSO OR SCOLIOSIS ORTH
ADDITIONS TO CTLSO OR SCOLIOSIS ORTH
ADDITIONS TO CTLSO OR SCOLIOSIS ORTH
ADDITIONS TO CTLSO OR SIO, SCOLIOSIS
THORACIC-LUMBAR-SACAL-ORTHOSES (TLSO
ADDITIONS TO TLSO, (LOW PROFILE) LAT
ADDITIONS TO TLSO, (LOW PROFILE) ANT
ADDITIONS TO TLSO, (LOW PROFILE) MIL
ADDIT.TO TLSO LUMBAR DEROTATION PAD
ADDIT.TO TLSO ANTERIOR ASIS PAD(LOW
ADDIT.TO TLSO,ANTERIOR THORAC DEROTA
ADDIT.TO TLSO,ABDOMINAL PAD(LOW RROF
ADDIT.TO TLSO,RIB GUSSET(ELASTIC),EA
ADDIT.TO TLSO,LATERAL TROCHANTERIC P
OTHER SCOLIOSIS PROCEDURES, BODY JAC
OTHER SCOLIOSIS PROCEDURES, POST-OPE
UNLISTED PROCEDURE SPINAL ORTHOSIS
HIP ORTHOSIS, ABDUCTION CONTROL OF H
HIP ORTHOSIS, ABDUCTION CONTROL OF H
HIP ORTHOSIS, ABDUCTION CONTROL OF H
HO, ABDUCTION CONTROL OF HIP JOINTS,
HO, ABDUCTION CONTROL OF HIP JOINTS,
HO, ABDUCTION CONTROL OF HIP JOINTS,
HO, ABDUCTION CONTROL OF HIP JOINTS,
HO, ABDUCTION CONTROL OF HIP JOINTS,
HO CUSTOM ABDUCTION CONTROL OF HIP J
HO ABDUCTION CONTROL OF HIP JOINT PO
COMB BILATER, LUMBO-SACRAL, HIP,
LEGG PERTHES ORTHOSIS, TORONTO TYPE
LEGG PERTHES ORTHOSIS, NEWINGTON TYP
LEGG PERTHES ORTHOSIS, TRILATERAL, (
LEGG PERTHES ORTHOSIS, SCOTTISH RITE
LEG PERTHES ORTHOSIS,PATTEN BOTTOM T
KNEE ORTHOSIS, ELASTIC WITH JOINTS P
KNEE ORTHOSIS, ELASTIC WITH JOINTS,
KO, ELASTIC WITH CONDYLE PADS AND JO
KNEE ORTHOSIS, IMMOBILIZER, CANVAS L
KNEE ORTH POS LOCKING JOINT
KNEE ORTHOSIS, ADJUSTABLE KNEE JOINT
KNEE ORTHOSIS, ADJUSTABLE KNEE JOINT
KO W/O KNEE JOINT RIGID MOLDED TO PA
KO, DEROTATION, FABRICATED TO PATIEN
KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH
4
FEE
66.95
64.97
63.55
35.76
63.95
110.21
160.74
29.14
1,124.11
163.23
157.96
354.61
52.30
50.75
51.06
49.08
53.81
49.03
1,201.12
1,157.07
MP
107.18
28.39
83.58
105.70
331.46
152.22
142.34
898.54
742.02
569.05
1,296.99
1,070.06
1,376.00
1,020.77
808.03
987.64
66.72
81.74
89.75
54.57
212.88
379.25
464.62
484.23
704.79
601.80
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
00
20
REPORT NO:
RF-0-76D
PAGE:
25
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20140101
20120701
20120701
20120701
20120701
20140101
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L1844 09
L1845 09
L1846 09
L1847 09
L1848 09
L1850 09
L1860 09
L1900 09
L1902 09
L1904 09
L1906 09
L1907 09
L1910 09
L1920 09
L1930 09
L1932 09
L1940 09
L1945 09
L1950 09
L1960 09
L1970 09
L1971 09
L1980 09
L1990 09
L2000 09
L2005 09
L2010 09
L2020 09
L2030 09
L2035 09
L2036 09
L2037 09
L2038 09
L2040 09
L2050 09
L2060 09
L2070 09
L2080 09
L2090 09
L2106 09
L2108 09
L2112 09
L2114 09
L2116 09
L2126 09
L2128 09
L2132 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
KO, SINGLE UPRIGHT, THIGH AND CALF,
KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH
KO,DBL UPRIGHT THIGH/CALF MOLDED TO
KNEE ORTHOSIS, DOUBLE UPRIGHT WITH A
KNEE ORTHOSIS, DOUBLE UPRIGHT WITH A
KNEE ORTHOSIS, SWEDISH TYPE, PRFABRI
KO, MODIFICATION OF SUPRACONDYLAR PR
SHORT LEG BRACE, SPRING WIRE
ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET
ANKLE ORTHOSIS, ANKLE GAUNTLET, CUST
ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS
ANKLE ORTHOSIS, SUPRAMALLEOLAR WITH
SHORT LEG BRACE, SINGLE UPRIGHT PERL
AFO,SINGLE UPRIGHT WITH STATIC OR A
AFO,CUSTOM FITTED, PLASTIC
AFO RIG ANT TIB PREFAB TCF/=
AFO,MOLDED TO PATIENT MODEL, PLASTI
AFO,PLASTIC FLOOR REACTION MOLDED TO
AFO,SPIRAL, MOLDED TO PATIENT MODEL
AFO,POSTERIOR SOLID ANKLE, MOLDED T
AFO,PLASTIC MOLDED TO PATIENT MODEL
AFO W/ANKLE JOINT, PREFAB
AFO,SINGLE UPRIGHT FREE PLANTAR DOR
SHT LEG BR 2 BAR UP-RIGHT LOWER LEG
KNEE-ANKLE-FOOT-ORTHOSES (KAFO), SIN
KNEE ANKLE FOOT ORTHOSIS, ANY MATERI
KAFO, SINGLE UPRIGHT, FREE KNEE, FRE
KAFO, DOUBLE UPRIGHT, FREE KNEE, FRE
LONG LEG BRACE, FULL-LENGTH W/O KNEE
KAFO PLASTIC PEDIATRIC SIZE
KAFO FULL PLASTIC MOLDED TO PT.MODEL
KAFO PLASTIC SINGLE WPRIGHT FREE KNE
KAFO PLASTIC W/O KNEE JOINT MULTI AX
HIP-KNEE-ANKLE-FOOT, ORTHOSES TORSIO
HKAFO, TORSION CONTROL, BILATERAL TO
HKAFO, TORSION CONTROL, BILATERAL TO
HKAFO, TORSION CONTROL, UNILATERAL R
HKAFO, TORSION CONTROL, UNILATERAL,
HKAFO, TORSION CONTROL, UNILATERAL T
AFO,FRACTURE ORTHOSIS TIBIAL THERMOP
AFO,FRACTURE ORTHOSIS,TICIAL MOLD TO
AFO,TIBIAL FRACTURE ORTHOSIS-SOFT EU
AFO,FRACTURE ORTHOSIS TIBIAL SEMI RI
AFO,TIBIAL FRACTURE ORTHO.RIGID CUST
KAFO FRACTURE ORTHOSIS MOLDED TP PAT
KAFO,FEMORAL FRACTURE CAST ORTHO.MOL
SOFT CUST.FIT,KAFO-FEMORAL FRACTURE
4
FEE
1,041.05
584.30
721.58
385.78
472.59
207.62
682.23
216.12
66.40
293.35
75.02
377.41
187.94
225.81
196.76
598.51
315.88
577.47
466.25
345.77
443.89
314.38
239.32
278.07
632.73
2,748.37
617.87
728.39
638.91
116.19
1,216.15
1,039.03
891.89
110.75
352.50
407.83
84.51
239.75
290.55
522.00
725.22
353.33
409.03
490.04
746.99
1,069.68
567.69
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
26
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20140101
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L2134 09
L2136 09
L2180 09
L2182 09
L2184 09
L2186 09
L2188 09
L2190 09
L2192 09
L2200 09
L2210 09
L2220 09
L2230 09
L2240 09
L2250 09
L2260 09
L2265 09
L2270 09
L2275 09
L2280 09
L2300 09
L2310 09
L2320 09
L2330 09
L2335 09
L2340 09
L2350 09
L2360 09
L2370 09
L2375 09
L2380 09
L2385 09
L2390 09
L2395 09
L2397 09
L2405 09
L2415 09
L2425 09
L2430 09
L2492 09
L2500 09
L2510 09
L2520 09
L2525 09
L2526 09
L2530 09
L2540 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
KAFO FRACTURE ORTHOSIS FEMORAL FRACT
KAFO,FEMORAL FRACTURE CAST RIGID CUS
AFO,FRACTURE ORTHOSIS TIBIAL FRACTUR
ADD TO LOW EXTREMITY FX ORTH DROP LO
LIMITED MOTION KNEE JOINT,ADDIT.TO L
ADJ.MOTION KNEE JOINT,ADDIT.TO LOWER
QUADRILATERAL BRIM-ADDIT.TO LOWER EX
WAIST BELT-ADDIT.TO LOWER ESTREM.FRA
HIP JOINT,PELVIC BAND.FLANGE,PELVIC
ADDITIONS TO LOWER EXTREMITY, LIMITE
ADDITIONS TO LOWER EXTREMITY, DORSIF
ADDITIONS TO LOWER EXTREMITY, DORSIF
ADDITIONS TO LOWER EXTREMITY, SPLIT
ADDITIONS TO LOWER EXTREMITY, ROUND
ADDITIONS TO LOWER EXTREMITY, FOOT P
ADDITIONS TO LOWER EXTREMITY, REINFO
ADDITION TO LOWER EXTREMITY LONG TON
ADDITIONS TO LOWER EXTREMITY, VARUS/
ADDITION TO LOWER EXT,VARUS/VALGUS C
ADDITIONS TO LOWER EXTREMITY, MOLDED
ADDITIONS TO LOWER EXTREMITY, ABDUCT
ADDITIONS TO LOWER EXTREMITY,ABDUC
BRACE; LONG BOWLEG OR KNOCK-KNEE
ADDITIONS TO LOWER EXTREMITY, LACER
ANTERIOR SWING BAND-ADDIT.TO LOWER E
ADDITIONS TO LOWER EXTREMITY, PRE-T
ADDITIONS TO LOWER EXTREMITY, PROSTH
ADDITIONS TO LOWER EXTREMITY, EXTEN
PATTEM BOTTOM-ADDIT TO LOWER EXTREMI
TORSON CTRL,ANKLE JOINT/HALF SOL STI
TORSION CTRL,STRAIGHT KNEE JOINT,ADD
ADDITION TO LOWER EXTREMITY STRAIGHT
ADDITION TO LOWER EXTREMITY OFFSET K
ADDITION TO LOWER EXTREMITY OFFSET K
ADDITION TO LOWER EXT,SUSPENSION SLE
DROP LOCK,EACH JOINT ADD TO STRAIGHT
ADD.TO KNEE JOINT,CAM LOCK,EA.JOINT
ADD.TO KNEE JOINT,DISC/DIAL LOCK FOR
LONG LEG BRACES FOR HEMOPHILIACS, BI
ADDITION TO LOWER EXTREMITY OFFSET K
ADDITIONS LOWER EXTREMITY BRACE,RING
ADDITIONS TO LOWER EXTREMITY, THIGH/
ADDITIONS TO LOWER EXTREMITY, THIGH/
ADD TO LOWER EXTREMITY THIGH/WEIGHT
ADD TO LOWER EXTREMITY CUSTOM FITTED
ADDITION/LOWER EXTREMITY BRACE,LACER
ADDITIONS TO LOWER EXTREMITY, THIGH/
4
FEE
710.02
803.85
97.41
71.56
92.97
93.92
218.53
62.45
246.04
39.54
41.94
54.50
50.36
52.17
221.66
129.04
97.96
33.49
81.51
282.47
223.94
102.32
140.02
259.61
141.72
345.73
592.31
43.03
183.07
93.97
102.40
107.87
68.28
130.14
73.10
58.47
81.47
96.14
96.14
71.00
229.47
520.49
328.57
760.42
427.28
147.77
280.54
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
27
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L2550 09
L2570 09
L2580 09
L2600 09
L2610 09
L2620 09
L2622 09
L2624 09
L2627 09
L2628 09
L2630 09
L2640 09
L2650 09
L2660 09
L2670 09
L2680 09
L2750 09
L2755 09
L2760 09
L2768 09
L2780 09
L2785 09
L2795 09
L2800 09
L2810 09
L2820 09
L2830 09
L2840 09
L2850 09
L2861 09
L2999 09
L3000 07
L3000 09
L3001 07
L3001 09
L3002 07
L3002 09
L3003 07
L3003 09
L3010 07
L3010 09
L3020 07
L3020 09
L3030 07
L3030 09
L3040 07
L3040 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
ADDITIONS TO LOWER EXTREMITY, THIGH/
ADDITIONS TO LOWER EXTREMITY, GLUTEA
ADDS TO LOWER EXT.BRACE PELVIC SLING
ADDITIONS TO LOWER EXTREMITY, PELVIC
ADDITIONS TO LOWER EXTREMITY, PELVIC
LONG LEG BRACE; PELVIC BAND, REG. HI
PELVIC CTRL,HIP JOINT,ADJ.FLEX-ADD T
PELVIC CTRL,HIP JOINT,ADJ.FLEX EXT A
ADD TO LOWER EXTREMITY PELVIC CONTRO
ADD TO LOWER EXTREMITY PELVIC CONTRO
ADDITIONS TO LOWER EXTREMITY, PELVIC
BRACE; PELVIC BAND W/ BALL-BEARING J
COVERED ATTACHMENTS TO BRACES; PELVI
ADDITIONS TO LOWER EXTREMITY, THORAC
ATTACHMENT TO BRACE; SHOULDER HARNES
ADDITIONS TO LOWER EXTREMITY, THORAC
ADDITION TO LOWER EXTREMITY ORTHOSES
CARBON GRAPHITE LAMINATION
ADDITIONS TO LOWER EXTREMITY ORTHOSE
ORTHO SIDEBAR DISCONNECT
ADDITIONS TO LOWER EXTREMITY, NON-CO
ADD.TO LOWER EXTREM.ORTH,DROP LOCK R
ADD TO LOWER EXTREMITY FULL KNEE CAP
KNEE CTRL,KNEE CAP,MEDIAL/PULL ADDIT
KNEE CTRL,CONDYLAR PAD-ADD.TO LOW EX
SOFT INTERFACE FOR MOLD PLASTIC KNEE
ADDIT.TO LOWER EXTREMITY-SOFT INTERF
ADD TO LOWER EXTREMITY ORTHOSIS EACH
ADD TO LOWER EXTREMITY ORTHOSIS EACH
ADDITION TO LOWER EXTREMITY JOINT, K
UNLISTED PROCEDURES FOR LOWER EXTREM
FOOT,INSERT,REMOVEABLE,MOLDED TO P
FOOT, INSERT, REMOVABLE, MOLDED TO P
FOOT,INSERT,REMOVABLE,MOLDED TO
FOOT, INSERT, REMOVABLE, MOLDED TO
FOOT,INSERT,REMOVABLE,MOLDED TO
FOOT, INSERT, REMOVABLE, MOLDED TO
FOOT,INSERT,REMOVABLE,MOLDED TO
FOOT, INSERT, REMOVABLE, MOLDED TO
FOOT,INSERTM REMOVABLE,MOLDED TO P
FOOT, INSERT, REMOVABLE, MOLDED TO P
FOOT,INSERT,REMOVABLE MOLDED TO P
FOOT, INSERT, REMOVABLE, MOLDED TO P
FOOT,INSERT,REMOVABLE FORMED TO P
FOOT, INSERT, REMOVABLE, FORMED TO P
FOOT,ARCH SUPPORT,REMOVABLE,PREMO
FOOT, ARCH SUPPORT, REMOVABLE, PREMO
4
FEE
179.17
396.17
289.52
170.82
201.98
195.16
255.06
221.81
1,069.39
1,045.14
182.66
240.13
90.18
140.42
141.89
130.16
68.56
87.65
50.54
102.68
42.21
19.77
61.08
66.52
54.24
54.17
58.61
36.33
41.55
MP
MP
105.94
210.69
53.86
88.69
46.79
108.32
46.79
116.86
53.86
116.86
53.86
133.06
53.86
53.86
53.86
53.86
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
1
1
1
1
1
1
1
1
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
28
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L3050 07
L3050 09
L3060 07
L3060 09
L3070 07
L3070 09
L3080 07
L3080 09
L3090 07
L3090 09
L3100 07
L3100 09
L3140 09
L3150 09
L3160 07
L3160 09
L3170 07
L3170 09
L3201 09
L3202 09
L3203 09
L3204 09
L3206 09
L3207 09
L3208 09
L3209 09
L3211 09
L3212 09
L3213 09
L3214 09
L3215 09
L3216 09
L3217 09
L3219 09
L3221 09
L3222 09
L3224 09
L3225 09
L3230 09
L3250 07
L3250 09
L3251 09
L3252 09
L3253 09
L3254 09
L3255 09
L3260 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
FOOT,ARCH SUPPORT,REMOVABLE,PREMO
FOOT, ARCH SUPPORT, REMOVABLE, PREMO
FOOT,ARCH SUPPORT,REMOVABLE,PREMO
FOOT, ARCH SUPPORT, REMOVABLE, PREMO
FOOT,ARCH SUPPORT,NON-REMOVABLE AT
FOOT, ARCH SUPPORT, NON-REMOVABLE AT
METATARSAL PAD
METATARSAL PAD
FOOT, ARCH SUPPORT, NONREMOVABLE AT
FOOT, ARCH SUPPORT, NON-REMOVABLE AT
HALLUS-VALGUS NIGHT DYNAMIC SPLINT,
HALLUS-VALGUS NIGHT DYNAMIC SPLINT,
FOOT, ABDUCTION ROTATION BARS (DENNI
FOOT, ABDUCTION ROTATION BARS (DENNI
FOOT, TORQUE HEELS
FOOT, TORQUE HEELS
FOOT, PLASTIC, SILICONE OR EQUAL, HE
FOOT, PLASTIC, SILICONE OR EQUAL, HE
ORTHOPEDIC SHOE, OXFORD WITH SUPINA
ORTHOPEDIC SHOE, OXFORD WITH SUPINA
ORTHOPEDIC SHOE, OXFORD WITH SUPINA
ORTHOPEDIC SHOE, HIGHTOP WITH SUPIN
ORTHOPEDIC SHOE, HIGHTOP WITH SUPIN
ORTHOPEDIC SHOE, HIGHTOP WITH SUPIN
SURGICAL BOOT, EACH, INFANT
SURGICAL BOOT, EACH, CHILD
SURGICAL BOOT, EACH, JUNIOR
BENESCH BOOT,INFANT,PAIR
BENESCH BOOT,CHILD,PAIR
BENESCH BOOT,JUNIOR,PAIR
ORTHOPEDIC FOOTWEAR, LADIES SHOES, O
ORTHOFOOTWEAR,LADIESSHOES DEPTHINLAY
ORTHOFOOTWEAR,LADIESHITOP DEPTHINLAY
ORTHOPEDICFOOTWEAR,MENS SHOES,OXFORD
ORTHOPEDIC FOOTWEAR, MENS SHOES, DE
ORTHOPEDIC FOOTWEAR, MENS SHOES, HI
WOMAN'S SHOE OXFORD BRACE
MAN'S SHOE OXFORD BRACE
ORTHOPEDIC FOOTWEAR, CUSTOM SHOES, D
ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED
ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED
FOOT, SHOE MOLDED TO PATIENT MODEL,
FOOT, SHOE MOLDED TO PATIENT MODEL,
FOOT, MOLDED SHOE PLASTAZOTE (OR SI
NON-STANDARD SIZE OR WIDTH
NON-STANDARD SIZE OR LENGTH
AMBULATORY SURGICAL BOOT, EACH
4
FEE
53.86
53.86
53.86
53.86
7.95
21.32
7.95
21.32
7.95
27.31
21.62
29.00
59.72
54.59
61.80
MP
44.14
44.14
44.14
44.14
44.14
44.14
44.14
44.14
60.03
60.03
60.03
88.29
88.29
88.29
69.69
88.29
88.29
81.68
88.29
88.29
MP
MP
317.82
158.91
158.91
158.91
158.91
158.91
57.39
57.39
60.03
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
29
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L3265 09
L3300 07
L3300 09
L3310 07
L3310 09
L3320 07
L3320 09
L3330 09
L3332 07
L3332 09
L3334 07
L3334 09
L3340 07
L3340 09
L3350 07
L3350 09
L3360 07
L3360 09
L3370 07
L3370 09
L3380 07
L3380 09
L3390 07
L3390 09
L3400 07
L3400 09
L3410 09
L3420 09
L3430 09
L3440 09
L3450 07
L3450 09
L3455 07
L3455 09
L3460 07
L3460 09
L3465 07
L3465 09
L3470 07
L3470 09
L3480 07
L3480 09
L3485 07
L3485 09
L3500 07
L3500 09
L3510 07
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
PLASTAZOTE SANDAL, EACH
LIFTS,ELEVATION,HEELTAPERED TO M
LIFTS, ELEVATION, HEEL, TAPERED TO M
LIFTS,ELEV,HEEL&SOLE,NEOPRENE,PERINC
LIFT,ELEV,HEEL&SOLE,NEOPRENE,PERINCH
SHOE EXTENSION, CORK
SHOE EXTENSION, CORK
SHOE EXTENSION, METAL
LIFT,ELEV,IN SHOE TAPERED,UP TO 1/2I
LIFT,ELEV,IN SHOE,TAPERED,UPTO 1/2IN
LIFTS,ELEVATION,HEL PER INCH
LIFTS, ELEVATION, HEEL, PER INCH
HEEL WEDGE,SACH
HEEL WEDGE, SACH
HEEL WEDGE
HEEL WEDGE
SOLE WEDGE,OUTSIDE SOLE
SOLE WEDGE, OUTSIDE SOLE
SOLE WEDGE,BETWEEN SOLE
SOLE WEDGE, BETWEEN SOLE
CLUBFOOT WEDGE
CLUBFOOT WEDGE
OUTFLARE WEDGE
OUTFLARE WEDGE
METATARSAL BAR WEDGE,ROCKER
METATARSAL BAR WEDGE, ROCKER
METATARSAL BAR WEDGE, BETWEEN SOLE
FULL SOLE AND HEEL WEDGE, BETWEEN SO
HEEL, COUNTER, PLASTIC REINFORCED
HEEL, COUNTER, LEATHER REINFORCED
HEEL, SAC CUSHION TYPE
HEEL, SACH CUSHION TYPE
HEEL, NEW LEATHER,STANDARD
HEEL, NEW LEATHER, STANDARD
HEEL, NEW RUBBER,STANDARD
HEEL, NEW RUBBER, STANDARD
HEEL,THOMAS WITH EDGE
HEEL, THOMAS WITH WEDGE
HEE, THOMAS EXTENDED TO BALL
HEEL, THOMAS EXTENDED TO BALL
HEEL,PAD AND DEPRESSION FOR SPUR
HEEL, PAD AND DEPRESSION FOR SPUR
HEEL, PAD REMOVABLE FOR SPUR
HEEL, PAD, REMOVABLE FOR SPUR
MISCELLANEOUS SHOE ADDITIONS, INSOLE
MISCELLANEOUS SHOE ADDITIONS, INSOLE
MISCELLANEOUS SHOE ADDITIONS, INSOLE
4
FEE
158.91
12.36
34.96
43.27
54.59
43.27
81.66
379.59
81.66
51.20
12.36
25.59
9.72
57.15
9.72
15.33
9.72
23.88
9.72
33.25
9.72
33.25
9.72
33.25
16.78
27.31
62.29
65.77
107.49
65.77
65.77
70.78
65.81
65.77
65.77
65.77
7.95
39.23
7.95
41.79
65.77
65.77
65.77
65.77
65.77
65.77
65.77
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
30
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L3510 09
L3520 07
L3520 09
L3530 09
L3540 07
L3540 09
L3550 07
L3550 09
L3560 07
L3560 09
L3570 07
L3570 09
L3580 07
L3580 09
L3590 07
L3590 09
L3595 07
L3595 09
L3600 07
L3600 09
L3610 07
L3610 09
L3620 07
L3620 09
L3630 07
L3630 09
L3640 09
L3649 09
L3650 09
L3670 09
L3710 09
L3720 09
L3730 09
L3740 09
L3760 09
L3763 09
L3764 09
L3806 09
L3807 09
L3808 09
L3809 09
L3891 09
L3900 09
L3901 09
L3904 09
L3906 09
L3908 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
MISCELLANEOUS SHOE ADDITIONS, INSOLE
MISCELLANEOUS SHOE ADDITIONS, INSOLE
MISCELLANEOUS SHOE ADDITIONS, INSOLE
MISCELLANEOUS SHOE ADDITIONS, SOLE,
MISCELLANEOUS SHOE ADDITIONS, SOLE
MISCELLANEOUS SHOE ADDITIONS, SOLE,
MISCELLANEOUS SHOE ADDITIONS, TOE TA
MISCELLANEOUS SHOE ADDITIONS, TOE TA
MISCELLANEOUS SHOE ADDITIONS, TOE,TA
MISCELLANEOUS SHOE ADDITIONS, TOE TA
MISCELLANEOUS SHOE ADDITIONS, SPECIA
MISCELLANEOUS SHOE ADDITIONS, SPECIA
MISCELLANEOUS SHOE ADDITIONS,CONVER
MISCELLANEOUS SHOE ADDITIONS, CONVER
MISCELLANEOUS SHOE ADDITIONS, CONVER
MISCELLANEOUS SHOE ADDITIONS, CONVER
MISCELLANEOUS SHOE ADDITIONS, MARCH
MISCELLANEOUS SHOE ADDITIONS, MARCH
TRANS ORTHO,1 SHOE-ANOTHER,CALIPER P
TRANS ORTHO,1SHOE-ANOTHER,CALIPER PL
TRANS ORTHO,1 SHOE-ANOTHER,CALIPER P
TRANS ORTHO,1SHOE-ANOTHER,CALIPER PL
TRANSFERS OF AN ORTHOSIS FROM ONE SH
TRANSFERS OF AN ORTHOSIS FROM ONE SH
TRANS ORTHO,1 SHOE-ANOTHER,SOLID STI
TRANS ORTHO,1SHOE-ANOTHER,SOLID STIR
TRANSFERS OF AN ORTHOSIS FROM ONE SH
UNLISTED PROCEDURES FOR FOOT ORTHOPE
SHOULDER ORTHOSIS, FIGURE OF EIGHT D
SHOULDER ORTHOSIS, FIGURE OF EIGHT D
ELBOW ORTHOSIS, ELASTIC WITH METAL J
EO, DOUBLE UPRIGHT WITH FOREARM/ARM
EO, DOUBLE UPRIGHT WITH FOREARM/ARM
EO, DOUBLE UPRIGHT WITH FOREARM/ARM
EO WITHJOINT, PREFABRICATED
UPPEREXTREMITY FRACTURE ORTHOSIS, C
UPPER EXTREM FRAC OTHO FOREARM HAND
WRIST HAND FINGER ORTHOSIS, INCLUDES
WRIST HAND FINGER ORTHOSIS, WITHOUT
WRIST HAND FINGER ORTHOSIS, RIGID WI
WRIST HAND FINGER ORTHOSIS, PREFABRI
ADDITION TO UPPER EXTREMITY JOINT, W
HAND SPLINT
WHFO, DYNAMIC FLEXOR HINGE, RECIPROC
WHFO, EXTERNAL POWERED, ELECTRIC
WHFO, WRIST (GAUNTLET), MOLDED TO PA
WRIST HAND ORTHOSIS, WRIST EXTENSION
4
FEE
65.77
65.77
65.77
65.77
MP
65.77
2.66
5.97
2.66
15.33
65.77
65.77
MP
65.77
65.77
65.77
65.77
65.77
26.48
51.16
26.48
67.39
26.48
51.16
26.48
67.39
29.00
MP
39.67
71.67
90.68
463.15
677.44
869.87
305.27
371.81
356.78
MP
152.64
MP
187.00
MP
797.92
980.99
1,787.64
241.21
36.57
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
1
1
1
1
1
1
1
1
1
1
1
1
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
31
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20140101
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L3912 09
L3915 09
L3916 09
L3918 09
L3923 09
L3924 09
L3930 09
L3956 09
L3960 09
L3962 09
L3980 09
L3982 09
L3984 09
L3995 09
L3999 09
L4000 09
L4010 09
L4020 09
L4030 09
L4040 09
L4045 09
L4050 09
L4055 09
L4060 09
L4070 09
L4080 09
L4090 09
L4100 09
L4110 09
L4130 09
L4205 09
L4210 09
L4350 09
L4360 09
L4361 09
L4370 09
L4386 09
L4387 09
L4392 09
L4394 09
L4396 09
L4397 09
L4398 09
L5000 09
L5010 09
L5020 09
L5050 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
HAND FINGER ORTHOSIS (HFO), FLEXION
WRIST HAND ORTHOSIS, INCLUDES ONE OR
WHFO, WRIST EXTENSION (COCK-UP), WIT
HAND ORTHOSIS, METACARPAL FRAC ORTHO
HAND FINGER ORTHOSIS, WITHOUT JOINTS
HAND FINGER ORTHOSIS, WITHOUT JOINTS
HAND FINGER ORTHOSIS, INC NONTORSION
ADD JOINT UPPER EXT ORTHOSIS
SHOULDER-ELBOW-WRIST-HAND ORTHOSES,
ERBS PALSY SPLINT
UPPER EXTREMITY FRACTURE ORTHOSIS, H
UPPER EXTREMITY FRACTURE ORTHOSIS, R
UPPER EXTREMITY FRACTURE ORTHOSIS, W
ADD TO UPPER EXTREMITY ORTHOSIS SOCK
UNLISTED PROCEDURES FOR UPPER LIMB O
REPLACE GIRDLE FOR MILWAUKEE ORTHOSI
REPLACE TRILATERAL SOCKET BRIM
REPLACE QUADRILATERAL SOCKET BRIM, M
REPLACE QUADRILATERAL SOCKET BRIM, C
REPLACE MOLDED THIGH LACER
REPLACE NON-MOLDED THIGH LACER
REPLACE MOLDED CALF LACER
REPLACE NON-MOLDED CALF LACER
REPLACE HIGH ROLL CUFF
REPLACE PROXIMAL AND DISTAL UPRIGHT
METAL THIGH BAND
BR REPAIR METAL CALF BAND
BR REPAIR LEATHER THIGH BAND
BR REPAIR LEATHER CALF BAND
REPLACE PRETIBIAL SHELL
ORTHO DVC REPAIR PER 15 MIN
REPAIR OF ORTHOTIC DEVICE, REPAIR OR
ANKLE CONTROL ORTHOSIS, STIRRUP STYL
WALKING BOOT, PNEUMATIC AND/OR VACUU
WALKING BOOT, PNEUMATIC AND/OR VACUU
PNEUMATIC FULL LEG SPLINT, PREFABRIC
WALKING BOOT, NON-PNEUMATIC, WITH OR
WALKING BOOT, NON-PNEUMATIC, WITH OR
REPLACE ANKLE CONTRAC SPLINT
REPLACE FOOT DROP SPINT
STATIC OR DYNAMIC ANKLE FOOT ORTHOSI
STATIC OR DYNAMIC ANKLE FOOT ORTHOSI
FOOT DROP SPLINT, RECUMBENT POSITION
PARTIAL FOOT, SHOE INSERT WITH LONGI
PARTIAL FOOT, MOLDED SOCKET, ANKLE H
PARTIAL FOOT, MOLDED SOCKET, TIBIAL
ANKLE, SYMES, MOLDED SOCKET, SACH FO
4
FEE
76.09
MP
397.51
78.97
69.88
65.08
68.78
MP
546.98
437.98
224.71
253.58
220.60
26.04
MP
840.57
429.58
628.20
410.82
267.75
204.63
257.54
169.88
198.24
221.00
63.09
71.27
73.18
58.54
360.71
MP
MP
57.35
172.72
211.61
117.76
106.34
130.28
MP
MP
MP
137.92
MP
447.73
1,016.63
1,527.21
1,922.55
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
32
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20140101
20140101
20120701
20140101
20140101
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20140101
20120701
20120701
20140101
20140101
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L5060 09
L5100 09
L5105 09
L5150 09
L5160 09
L5200 09
L5210 09
L5220 09
L5230 09
L5250 09
L5270 09
L5280 09
L5301 09
L5311 09
L5312 09
L5321 09
L5331 09
L5500 09
L5505 09
L5510 09
L5520 09
L5530 09
L5535 09
L5540 09
L5560 09
L5570 09
L5580 09
L5585 09
L5590 09
L5595 09
L5600 09
L5610 09
L5611 09
L5613 09
L5614 09
L5616 09
L5617 09
L5618 09
L5620 09
L5622 09
L5624 09
L5626 09
L5628 09
L5629 09
L5630 09
L5631 09
L5632 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
ANKLE, SYMES, METAL FRAME, MOLDED LE
BELOW KNEE, MOLDED SOCKET, SHIN, SAC
B/K PLASTIC SOCKET SACH FOOT JOINTS
KNEE DISARTICULATION (OR THROUGH KNE
KNEE DISARTICULATION (OR THROUGH KNE
ABOVE KNEE MOLDED SOCKET, SINGLE AX
ABOVE KNEE SHORT PROSTHESIS, NO KNE
ABOVE KNEE SHORT PROSTHESIS, NO KNE
ABOVE KNEE FOR PROXIMAL FEMORAL FOC
HIP DISARTICULATION, CANADIAN TYPE;
HIP DISARTICULATION, TILT TABLE TYPE
HEMIPELVECTOMY, CANADIAN TYPE; MOLDE
BELOW KNEE, MOLDED SOCKET, SACH FOOT
KNEE DISART, SACH FT, ENDO
KNEE DISARTICULATION (OR THROUGH KNE
ENDOSKELETAL ALK/W FOAM BODY
HIP DISART CANADIAN SACH FT
PREPARATORY, BELOW KNEE ("PTB" (TYPE
PREPARATORY, ABOVE KNEE DISARTICULAT
PREPARATORY, BELOW KNEE ("PTB" (TYPE
PREPARATORY, BELOW KNEE, ("PTB" (TYP
PREPARATORY, BELOW KNEE ("PTB" (TYPE
PREP B/K PTB SOCKET USMC SACH FOOT
PREPARATORY, BELOW KNEE ("PTB" (TYPE
PREPARATORY, ABOVE KNEE, DISARTICULA
PREPARATORY, ABOVE KNEE, DISARTICULA
PREPARATORY, ABOVE KNEE DISARTICULAT
KNEE DISART SACH FOOT ISCHIAL SOCKET
PREPARATORY, ABOVE KNEE DISARTICULAT
PREP HIP DISART-HEMIPEL SACH MOLDED
PREP HIP DISART-HEMIPEL SACH LAMINAT
ADDITIONS TO LOWER EXTREMITY, ABOVE
ADD TO LOWER EXTREMITY A/K W/FRICTIO
ADD TO LOWER EXTREMITY A/K HYDRAULIC
ADDITION TO LOWER EXT, AK DISARTICUL
ADDITIONS TO LOWER EXTREMITY, ABOVE
AK/BK SELF-ALIGNING UNIT EA
ADDITIONS TO LOWER EXTREMITY, TEST S
BELOW KNEE ADD TEST SOCKETS
ADDITIONS TO LOWER EXTREMITY, TEST S
OPEN-END SOCKET FOR TEMP. A/K (WOOD)
ADDITIONS TO LOWER EXTREMITY, TEST S
ADDITIONS TO LOWER EXTREMITY, TEST S
BELOW KNEE ACRYLIC SOCKET ADD TEST S
ADDITIONS TO LOWER EXTREMITY, SYMES
ADD TO LOWER EXTREMITY A/K ACRYLIC
PLASTIC HARD SOCKET FOR PTB ENDOSKEL
4
FEE
2,172.37
1,889.20
2,308.80
2,752.03
2,895.47
2,516.39
1,860.01
2,336.74
2,769.69
3,749.63
3,562.91
3,878.42
1,832.91
2,446.41
2,289.59
2,557.17
3,849.75
953.73
1,541.26
1,133.85
1,274.30
1,316.93
1,319.50
1,414.76
1,701.49
1,679.92
1,875.76
1,881.94
1,841.33
2,676.02
2,955.12
1,594.74
1,070.79
1,649.33
1,133.98
1,203.50
375.98
200.78
246.35
321.23
322.16
353.78
381.80
281.61
343.77
389.34
147.57
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
33
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L5634 09
L5636 09
L5637 09
L5638 09
L5639 09
L5640 09
L5642 09
L5643 09
L5644 09
L5645 09
L5646 09
L5647 09
L5648 09
L5649 09
L5650 09
L5651 09
L5652 09
L5653 09
L5654 09
L5655 09
L5656 09
L5658 09
L5661 09
L5665 09
L5666 09
L5668 09
L5670 09
L5671 09
L5672 09
L5673 09
L5676 09
L5678 09
L5679 09
L5680 09
L5681 09
L5682 09
L5683 09
L5684 09
L5685 09
L5686 09
L5688 09
L5690 09
L5692 09
L5694 09
L5695 09
L5696 09
L5697 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
ADDITIONS TO LOWER EXTREMITY, SYMES
ADDITIONS TO LOWER EXTREMITY, SYMES
ADD TO LOWER EXTREMITY B/K TOTAL COM
ADDITIONS TO LOWER EXTREMITY, BELOW
ADD TO LOWER EXTREMITY B/K WOOD SOCK
ADDITIONS TO LOWER EXTREMITY, KNEE D
SOCKET/THIGH; MOLDED GLUTEAL CORSET;
ADD TO LOW EXT HIP DISARTIC FLEX INN
SOCKET/THIGH; WOOD, OPEN-END (STANDA
ADD TO LOW EXT BELOW KNEE FLEX INNER
AIR-CUSHION PTB SOCKET FOR ENDOSKELE
ADD TO LOW EXT BELOW KNEE SUCTION SO
SOCKET/THIGH; PLASTIC, A/K, TOTAL CO
ADD TO LOW EXT, ISCHIAL CONTAINMENT
PLASTIC TOTAL CONTACT STD A/K SOCKET
ADD TO LOW EXT ABOVE KNEE FLEX INNER
ADDITIONS TO LOWER EXTREMITY, SUCTIO
ADDITIONS TO LOWER EXTREMITY, KNEE D
ADDITIONS TO LOWER EXTREMITY, SOCKET
ADDITIONS TO LOWER EXTREMITY, SOCKET
ADDITIONS TO LOWER EXTREMITY, SOCKET
ADDITIONS TO LOWER EXTREMITY, SOCKET
ADD TO LOW EXT SOCKET INSERT MULTI D
ADD TO LOW EXT BELOW KNEE SOCKET INS
ADDITIONS TO LOWER EXTREMITY, BELOW
ADDITIONS TO LOWER EXTREMITY, BELOW
ADDITIONS TO LOWER EXTREMITY, BELOW
BK/AK LOCKING MECHANISM
ADDITIONS TO LOWER EXTREMITY, BELOW
SOCKET INSERT W LOCK MECH
ADDITIONS TO LOWER EXTREMITY, BELOW
ADDITIONS TO LOWER EXTREMITY, BELOW
SOCKET INSERT W/O LOCK MECH
THIGH CORSET; STANDARD LEATHER FOR B
INTL CUSTM CONG/LATYP INSERT
THIGH CORSET; GLUTEAL, MOLDED FOR B/
INITIAL CUSTOM SOCKET INSERT
ADDITIONS TO LOWER EXTREMITY, BELOW
BELOW KNEE SUS/SEAL SLEEVE
ADDITIONS TO LOWER EXTREMITY, BELOW
ADDITIONS TO LOWER EXTREMITY, BELOW
HVY. DUTY UNILATERAL B/K BELT
ADDITIONS TO LOWER EXTREMITY, ABOVE
ADDITIONS TO LOWER EXTREMITY, ABOVE
ADD TO LOWER EXTREMITY A/K SLEEVE SO
ADDITIONS TO LOWER EXTREMITY, ABOVE
ADDITIONS TO LOWER EXTREMITY, ABOVE
4
FEE
202.16
169.34
255.99
335.47
745.13
424.96
424.67
1,112.53
468.29
531.34
472.68
528.66
515.58
1,614.79
380.71
1,064.17
338.04
395.93
261.98
203.82
252.61
241.64
404.44
363.67
62.03
89.47
240.45
382.11
198.17
486.89
313.65
35.19
405.73
216.93
883.97
424.06
883.97
35.77
86.07
35.91
51.04
71.70
117.75
160.75
144.51
147.52
53.34
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
34
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L5698 09
L5699 09
L5700 09
L5701 09
L5702 09
L5704 09
L5705 09
L5706 09
L5707 09
L5710 09
L5711 09
L5712 09
L5714 09
L5716 09
L5718 09
L5722 09
L5724 09
L5726 09
L5728 09
L5780 09
L5785 09
L5790 09
L5795 09
L5810 09
L5811 09
L5812 09
L5814 09
L5816 09
L5818 09
L5822 09
L5824 09
L5826 09
L5828 09
L5830 09
L5840 09
L5845 09
L5850 09
L5855 09
L5859 09
L5910 09
L5920 09
L5925 09
L5930 09
L5940 09
L5950 09
L5960 09
L5962 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
STD. SILESION BANDAGE
ALL LOWER EXTREMITY PROSTHESIS, SHOU
REPLACEMENT SOCKET,BK MOLDED TO PT.
REPLACEMENT SOCKET AK DISARTICULATIO
REPLACEMENT SOCKET,HIP DISARTICULATI
REPLACEMENT CUSTOM SHAPED BK PROTECT
REPLACEMENT CUSTOM SHAPED BK PROTECT
REPLACEMENT, CUSTOM SHAPED KNEE DISA
REPLACEMENT CUSTOM SHAPED HIP DISART
KNEE, ARTIFICIAL; BOCK, 3P4 W/ KNEE
ADD EXOSKEL KNEE-SHIN SYSTEM SINGLE
BOCK 3P23 KNEE ASSEMBLY
ADDITIONS, KNEE-SHIN SYSTEM, SINGLE
ADDITIONS, KNEE-SHIN SYSTEM, POLYCEN
ADDITIONS, KNEE-SHIN SYSTEM, POLYCEN
ADDITIONS, KNEE-SHIN SYSTEM, SINGLE
ADDITIONS, KNEE-SHIN SYSTEM, SINGLE
ADDITIONS, KNEE-SHIN SYSTEM, SINGLE
ADDITIONS, KNEE-SHIN SYSTEM, SINGLE
ADDITIONS, KNEE-SHIN SYSTEM, SINGLE
ADD EXOSKEL SYS BELOW KNEE ULTRA
ABOVE KNEE ADD TO EXOSKEL SYS ULTRA
HIP DISARTICULATION ULTRA-LIGHT RATE
ENDOSKEL KNEE-SHIN SYS SINGLE AXIS M
ULTRA-LIGHT ADD TO ENDOSKEL KNEE-SHI
ENDOSKELETAL SINGLE AXIS VARIFRICTIO
ADD ENDOSKEL KNEE-SHIN SINGLE AXIS
ADD ENDOSKEL KNEE-SHIN POLYCENTRI
POLYCENTRIC KNEE
ADD ENDOSKEL KNEE-SHIN SINGLE AXIS P
ADD ENDOSKEL KNEE-SHIN FLUID SWING S
PEDIATRIC KNEE JOINT
ENDOSKEL KNEE-SHIN SYS-SGL AXIS STAN
PNEUMATIC/HYDRAPNEU SWING CTRL ENDOS
ADDITION ENDOSKELETAL KNEE/SHIN SYST
KNEE-SHIN SYS STANCE FLEXION
ABOVE KNEE/HIP DISARTICULATE KNEE EX
ADDITION ENDOSKELETAL HIP DISARTICUL
ADDITION TO LOWER EXTREMITY PROSTHES
ADD ENDOSKEL SYS BELOW KNEE ALIGNABL
ABOVE KNEE/HIP DIS ALIGNABLE SYST
ADDITION ENDOSKELETAL AK DISARTICULA
HIGH ACTIVITY KNEE FRAME
ULTRA-LIGHT ADD ENDOSKEL SYS BELOW K
ULTRA-LIGHT ABOVE KNEE ADD ENDOSKEL
ULTRA-LIGHT MATERIAL FOR HIP DISC
ADDITION ENDOSKELETAL BK FLEXIBLE
4
FEE
79.53
123.92
1,904.02
2,286.60
2,892.89
356.19
636.46
623.91
822.55
284.44
360.33
377.59
319.01
563.88
622.12
604.77
1,337.54
1,541.49
1,646.88
876.70
384.98
637.15
951.43
357.25
529.20
400.44
MP
644.14
645.86
1,131.75
1,214.12
2,098.64
1,876.79
1,384.10
2,331.56
1,204.51
113.35
228.43
MP
320.93
470.17
297.75
2,261.95
444.49
689.42
854.27
421.62
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
35
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L5964 09
L5966 09
L5969 09
L5970 09
L5972 09
L5973 09
L5974 09
L5975 09
L5976 09
L5978 09
L5979 09
L5980 09
L5981 09
L5982 09
L5984 09
L5985 09
L5986 09
L5987 09
L5988 09
L5990 09
L5999 09
L6000 09
L6010 09
L6020 09
L6050 09
L6055 09
L6100 09
L6110 09
L6120 09
L6130 09
L6200 09
L6205 09
L6250 09
L6300 09
L6310 09
L6320 09
L6350 09
L6360 09
L6370 09
L6400 09
L6450 09
L6500 09
L6550 09
L6570 09
L6580 09
L6582 09
L6584 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
ADDITION ENDOSKELETAL AK FLEXIBLE
ADDITION ENDOSKELETAL HIP DISARTICUL
ADDITION, ENDOSKELETAL ANKLE-FOOT OR
ALL LOWER EXTREMITY PROSTHESES FOOT,
ALL LOWER EXTREMITY PROSTHESES FLEXI
ENDOSKELETAL ANKLE FOOT SYSTEM, MICR
ALL LOWER EXTREMITY PROSTHESES FOOT,
COMBO ANKLE/FOOT PROSTHESIS
ENERGY STORING FOOT DR EQUAL
LOWER EXTREMITY PROST.MULTIAXIAL FOO
ALL LOWER EXT PROSTHESES MULTIAXIAL
FLEX FOOT SYSTEM LOWER EXTREMITY PRO
ALL LOWER EXT PROSTHESES,FLEX-WALK S
AXIAL ROTATION UNIT LOWER EXTER PROS
AXIAL ROTATION UNIT LOWER ENDOSKELET
LWR EXT DYNAMIC PROSTH PYLON
MULTI-AXIAL ROTATION UNIT LOWER EXTR
SHANK FT W VERT LOAD PYLON
VERTICALSHOCK/ROTATION PYLON
USER ADJUSTABLE HEEL HEIGHT
UNLISTED PROCEDURES FOR LOWER EXTREM
PARTIAL HAND, THUMB REMAINING
PARTIAL HAND, LITTLE AND/OR RING FIN
PARTIAL HAND, NO FINGER REMAINING
WRIST DISARTICULATION, MOLDED SOCKET
WRIST DISARTICULATION MOLDED SOCKET
BELOW ELBOW, MOLDED SOCKET, FLEXIBLE
BELOW ELBOW, MOLDED SOCKET, (MUENSTE
BELOW ELBOW, MOLDED DOUBLE WALL SPLI
BELOW ELBOW, MOLDED DOUBLE WALL SPLI
ELBOW DISARTICULATION, MOLDED SOCKET
ELBOW DISARTICULATION MOLDED SOCKET
ABOVE ELBOW MOLDED DOUBLE WALL SOCK
SHOULDER DISARTICULATION, MOLDED SOC
SHOULDER DISARTICULATION, PASSIVE RE
SHOULDER DISARTICULATION, PASSIVE RE
INTERSCAPULAR THORACIC, MOLDED SOCKE
INTERSACPULAR THORACIC, PASSIVE REST
INTERSCAPULAR THORACIC, PASSIVE REST
BELOW ELBOW, MOLDED SOCKET, ENDOSKEL
ELBOW DISARTICULATION, MOLDED SOCKET
ABOVE ELBOW MOLDED SOCKET ENDOSKEL
SHOULDER DISARTICULATION, MOLDED SOC
INTERSCAPULAR THORACIC, MOLDED SOCKE
PREP WRIST DISARTIC/BELOW ELBOW SGL
DIRECT FORMED PREP WRIST DISARTICULA
MOLDED/PREP ELBOW DISARTICULATION OR
4
FEE
622.41
793.11
11,944.99
151.27
284.76
12,919.99
176.15
313.44
403.42
226.18
1,516.46
2,606.41
1,990.50
415.98
446.82
189.76
444.57
MP
1,428.75
1,219.19
MP
994.74
1,000.81
995.51
1,529.35
1,886.57
1,569.05
1,665.60
1,877.95
1,740.15
2,117.22
2,420.19
2,195.57
2,643.93
2,122.84
1,277.14
2,603.19
2,116.88
1,475.85
1,666.95
2,049.02
2,067.48
2,534.29
2,908.88
1,092.10
1,012.82
1,479.59
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
36
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20140101
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L6586 09
L6588 09
L6590 09
L6600 09
L6605 09
L6610 09
L6611 09
L6615 09
L6616 09
L6620 09
L6623 09
L6624 09
L6625 09
L6628 09
L6629 09
L6630 09
L6632 09
L6635 09
L6637 09
L6640 09
L6641 09
L6642 09
L6645 09
L6650 09
L6655 09
L6660 09
L6665 09
L6670 09
L6672 09
L6675 09
L6676 09
L6680 09
L6682 09
L6684 09
L6686 09
L6687 09
L6688 09
L6689 09
L6690 09
L6691 09
L6692 09
L6693 09
L6694 09
L6698 09
L6703 09
L6704 09
L6706 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
DIRECT FORMED PREP ELBOW/ABOVE ELBOW
PREP SHOULDER DISARTICULATE/INTERSCA
DIRECT FORMED PREP SHOULDER/INTERSCA
HOSMER POLYCENTRIC HINGE
HOSMER ELBOW HINGES FOR WD OR BE ARM
FLEXIBLE METAL HINGES FOR WD OR BE A
ADDITION TO UPPER EXTREMITY PROSTHES
FM WRIST DISCONNECT,FM-100
UPPER EXTREM ADD INSERT FOR LOCKING
HOSMER FLEXION WRIST,FW-500
UPPER EXTREMITY SPRING ASSISTED ROTA
UPPER EXTREMITY ADDITION, FLEXION/EX
ECONOMY FRICTION WRIST,WE-500
UPPER EXTREMITY QUICK RELEASE HOOK A
UPPER EXTREMITY QUICK DISCONNET LAM
OVAL FRICTION WRIST,OW-100N
UPPER EXTREMITY LATEX SUSP SLEEVE EA
HOSMER FOREARM LIFT ASSIST ELBOW,E-4
UPPER EXTREMITY NUDGE CONTROL ELBOW
HOSMER SHOULDER ABDUCTION JOINTS,SAJ
UPPER EXTREMITY EXCURSION AMPLIFIER
LEVER TYPE EXCURSION AMP UPPER EXTRA
HOSMER FLEXION-ABDUCTION JOINTS,FAJUPPER EXTREMITY ADDS,UNIVERSAL JOINT
UPPER EXTREMITY ADDITIONS, STANDARD
UPPER EXTREMITY ADDITIONS, HEAVY DUT
UPPER EXTREMITY ADDITIONS, TEFLON, O
UPPER EXTREMITY ADDITIONS, HOOK TO H
UPPER EXTREMITY ADDITIONS, HARNESS,
UNI. SWTCH CNTRL-RING/FIG.8 HARN.FOR
UNILATERAL FIG.& HARNESS FOR WD,BE,O
SOCKET & FOREARM FOR BE, PLASTIC TOT
SOCKET&UPPER ARM FORED,AE W,W/O MYOADJUSTABLE-FRICTION BULKHEAD JOINTS,
UPPER EXTREMITY ADDIT SUCTION SOCKET
FRAME TYPE SOCKET BELOW UPPER
FRAME TYPE SOCKET ABOVE ELBOW UPPER
FRAME TYPE SOCKET SHOULDER DISARTICU
FRAME TYPE SOCKET INTERSCAPULAR-THOR
UPPER EXTREMITY ADDIT REMOVABLE INSE
UPPER EXTER.ADD. SILICONE GEL INSERT
UPPER EXTR ADD.LOCKING ELBOW-FOREARM
ELBOW SOCKET INS USE W/LOCK
BELOW/ABOVE ELBOW LOCK MECH
TERMINAL DEVICE, PASSIVE HAND/MITT,
TERMINAL DEVICE, SPORT/RECREATIONAL/
TERMINAL DEVICE, HOOK, MECHANICAL, V
4
FEE
1,455.76
2,004.21
1,965.58
166.22
164.11
134.41
MP
129.03
54.84
222.95
447.66
MP
471.29
343.07
117.95
190.97
43.17
147.03
286.51
239.73
129.63
154.34
267.68
281.06
61.54
68.59
40.81
42.50
118.25
82.91
87.16
205.59
201.31
231.66
430.70
383.35
453.08
474.10
514.42
229.41
472.88
2,314.09
544.09
426.99
219.80
515.45
267.42
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
37
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20130801
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L6707 09
L6708 09
L6709 09
L6711 09
L6712 09
L6713 09
L6714 09
L6721 09
L6722 09
L6881 09
L6882 09
L6883 09
L6884 09
L6885 09
L6890 09
L6895 09
L6900 09
L6905 09
L6910 09
L6915 09
L6920 09
L6925 09
L6930 09
L6935 09
L6940 09
L6945 09
L6950 09
L6955 09
L6960 09
L6965 09
L6970 09
L6975 09
L7007 09
L7008 09
L7009 09
L7040 09
L7045 09
L7170 09
L7180 09
L7185 09
L7186 09
L7190 09
L7191 09
L7360 09
L7362 09
L7364 09
L7366 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
TERMINAL DEVICE, HOOK, MECHANICAL, V
TERMINAL DEVICE, HAND, MECHANICAL, V
TERMINAL DEVICE, HAND, MECHANICAL, V
TERMINAL DEVICE, HOOK, MECHANICAL, V
TERMINAL DEVICE, HOOK, MECHANICAL, V
TERMINAL DEVICE, HAND, MECHANICAL, V
TERMINAL DEVICE, HAND, MECHANICAL, V
TERMINAL DEVICE, HOOK OR HAND, HEAVY
TERMINAL DEVICE, HOOK OR HAND, HEAVY
AUTOGRASP FEATURE UL TERM DV
MICROPROCESSOR CONTROL UPLMB
REPLE SOCKT BELOW E/W DISA
REPLC SOCKT ABOVE ELBOW DISA
REPLC SOCKT SHLDR DIS/INTERC
REALASTIC GLOVES; PRODUCTION MODEL
REALASTIC GLOVES; CUSTOM MADE
HAND RESTORATION (CASTS, SHADING AND
HAND RESTORATION (CASTS, SHADING AND
HAND RESTORATION (CASTS, SHADING AND
HAND RESTORATION (SHADING, AND MEASU
WRIST DISARTICULATION EXTERNAL POWER
WRIST DISARTICULATION EXT POWER SELF
BELOW ELBOW EXTERNAL POWER
BELOW ELBOW ETT PWR SELF-SUSP INNER
ELBOW DISARTIC EXT PWR MOLDED INNER
ELBOW DISARTIC EXT MOLDED INNERABOVE ELBOW EXTERNAL POWER
ABOVE ELBOW EXTERNAL POWER
SHOU PROSTH EXTERNAL POWER
SHOU PROST EXT POWER MOLDED MYOELECT
INTERSCAPULAR-THORACIC EXT PWR MOLDE
INTERSCAPULAR-THORACIC EXT PWR MOLDE
ELECTRIC HAND, SWITCH OR MYOELECTRIC
ELECTRIC HAND, SWITCH OR MYOELECTRIC
ELECTRIC HOOK, SWITCH OR MYOELECTRIC
PREHENSILE ACTUATOR HOSMER/EQUAL SWI
ELEC HOOK CHILD MICH OR EQUAL SWITCH
SWITCH CTRL ELEC ELBOW HOSMER/EQUAL
MYOELEC CTRL ELBOW UTAH OR EQUAL
SWITCH CTRL ELEC ELBOW VARIETY VILLA
ELECTRONIC ELBOW CHILD SWITCH CONTRO
MYOELEC CTRL ELBOW VARIETY VILLAGE O
ELECTRONIC ELBOW CHILD MYOELECTRONIC
SIX VOLT BATTERY OTTO BOCK/EQUAL EA
BATTERY CHARGER 6 VOLT OTTO BOCK OR
TWELVE VOLT BATTERY UTAH OR EQUAL EA
BATTERY CHARGER 12 VOLT UTAH OR EQUA
4
FEE
951.53
639.51
938.28
504.88
929.59
1,173.23
993.72
1,766.12
1,522.61
3,332.38
2,084.02
1,240.12
1,861.18
2,116.88
122.51
371.11
1,027.58
975.78
961.55
416.05
4,870.26
5,142.57
5,228.79
5,751.61
6,534.85
7,392.45
6,947.81
8,718.53
8,596.91
12,558.85
12,765.22
12,833.74
MP
4,799.20
3,111.20
2,498.18
1,432.29
5,195.87
27,147.16
5,261.50
7,593.64
6,694.26
8,071.80
160.03
192.47
350.62
475.64
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
REPORT NO:
RF-0-76D
PAGE:
38
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20130901
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L7367 09
L7368 09
L7400 09
L7401 09
L7402 09
L7403 09
L7404 09
L7405 09
L7499 09
L7510 09
L7520 09
L8000 09
L8001 09
L8002 09
L8010 09
L8020 09
L8030 09
L8031 09
L8032 09
L8040 09
L8041 09
L8042 09
L8300 09
L8310 09
L8320 09
L8330 09
L8400 09
L8410 09
L8415 09
L8417 09
L8420 09
L8430 09
L8435 09
L8440 09
L8460 09
L8465 09
L8470 09
L8480 09
L8485 09
L8499 09
L8500 09
L8501 09
L8505 09
L8515 09
L8603 09
L8604 09
L8614 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
REPLACEMENT LITHIUM ZONBATTER
LITHIUM ION BATTERY CHARGER, REPLACE
ADD UE PROST BE/WD,ULTLITE
ADD UE PROST ALE ULTITE MGT
ADD UE PROST S/D ULTLITE MAT
ADD UE PROST B/C ACRYLIC
ADD UE PROST S/D ACRYLIC
ADD UE PROST S/D ACRYLIC
UNLISTED PROCEDURES FOR UPPER EXTREM
REPAIR PROSTHETIC DEVICE, REPAIR OR
REPAIR PROSTHESIS PER 15 MIN
MAMMARY PROSTHESIS INCLUDING SURGICA
BREAST PROSTHESIS BRA & FORM
BRST PRSTH BRA & BILAT FORM
BREAST PROSTHESES, MASTECTOMY SLEEVE
BREAST PROSTHESES, MASTECTOMY FORM
BREAST PROTHESIS, SILICONE OR EQUAL,
BREAST PROSTHESIS, SILICONE OR EQUAL
NIPPLE PROSTHESIS, REUSABLE, ANY TYP
NASAL PROSTHESIS
MIDFACIAL PROSTHESIS
ORBITAL PROSTHESIS
TRUSSES, SINGLE WITH STANDARD PAD
TRUSSES, DOUBLE WITH STANDARD PADS
TRUSSES, ADDITION TO STANDARD PADS,
TRUSSES, ADDITION TO STANDARD PADS,
PROSTHETIC SHEATH, BELOW KNEE, EACH
PROSTHETIC SHEATH, ABOVE KNEE, EACH
PROSTHETIC SHEATH UPPER LIMB EACH
PROS SHEATH/SOCK W GEL CUSHN
PROSTHETIC SOCK, WOOL, BELOW KNEE, E
PROSTHETIC SOCK WOOL ABOVE KNEE
PROSTHETIC SOCK WOOL UPPER LIMB EACH
BELOW KNEE STUMP SHRINKER ONE
ABOVE KNEE STUMP SHRINKER ONE
PROSTHETIC SHRINKER UPPER LIMB EACH
STUMP SOCK, SINGLE PLY, FITTING, BEL
STUMP SOCK SINGLE PLY FITTING
STUMP SOCK, SINGLE PLY, FITTING, UPP
UNLISTED PROCEDURE FOR MISCELLANEOUS
ARTIFICIAL LARYNX, ANY TYPE
TRACHEOSTOMY SPEAKING VALVE
ARTIFICIAL LARYNX, ACCESSORY
GEL CAP APP DEVICE FOR TRACH
COLLAGEN IMP URINARY 2.5 CC
INJECTABLE BULKING AGENT, DEXTRANOME
COCHLEAR IMPLANT DEVICE
4
FEE
261.63
339.16
205.95
230.57
249.00
247.48
373.51
488.48
MP
35.31
MP
24.93
84.28
110.86
74.79
151.00
221.68
MP
MP
MP
MP
MP
56.07
88.51
40.86
43.75
10.47
15.29
15.53
50.53
13.82
15.18
16.01
29.36
51.08
36.39
5.33
6.98
7.40
MP
516.69
89.71
31.78
42.42
291.02
MP
16,199.93
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
8
AGE
RESTRICTION
01
20
REPORT NO:
RF-0-76D
PAGE:
39
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20140501
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
L8615 09
L8616 09
L8617 09
L8618 09
L8619 09
L8621 09
L8622 09
L8623 09
L8624 09
L8627 09
L8628 09
L8629 09
L8690 09
L8691 09
L8692 09
L8695 09
L9900 09
Q0480 07
S1015 09
S1040 09
S8185 09
S8186 09
S8189 09
S8420 09
S8421 09
S8422 09
S8423 09
S8424 09
S8427 09
S8999 09
T4521 09
T4522 09
T4523 09
T4524 09
T4525 09
T4526 09
T4527 09
T4528 09
T4529 09
T4530 09
T4531 09
T4532 09
T4533 09
T4534 09
T4535 09
T4539 09
T4543 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
COCH IMPLANT HEADSET REPLACE
COCH IMPLANT MICROPHONE REPL
COCH IMPLANT TRANS COIL REPL
COCH IMPLANT TRAN CABLE REPL
COCHLEAR IMPLANT EXTERNAL
REPL ZINC AIR BATTERY
REPL ALKALINE BATTERY
REPL LITHIUM ION FOR USE WITH CO
REPL LITHIUM ION BAT FOR USE WITH CO
COCHLEAR IMPLANT, EXTERNAL SPEECH PR
COCHLEAR IMPLANT, EXTERNAL CONTROLLE
TRANSMITTING COIL AND CABLE, INTEGRA
AUDITORY OSSEOINTEGRATED DEVICE, INC
AUDITORY OSSEOINTEGRATED DEVICE, EXT
AUDITORY OSSEOINTEGRATED DEVICE, EXT
EXTERNAL RECHARGING SYSTEM FOR BATTE
O&P SUPPLY/ACCESSORY/SERVICE
DRIVER FOR USE W/PNEUMATIC VENTRICUL
IV TUBING EXTENSION SET
CRANIAL REMOLDING ORTHOSIS,CUSTOM FA
FLUTTER DEVICE
SWIVEL ADAPTOR
TRACHESOTOMY SUPPLY, NOC
GRAD PRESSURE AID,SLEEVE/GLOVE CUSTO
GRAD PRESSURE SLEEVE/GLOVE READ MADE
GRAD PRESS AID,SLEEVE,CUSTOM MEDIUM
GRAD PRESS AID,SLEEVE,CUSTOM HEAVY W
GRADIENT PRESSURE AID (SLEEVE) READY
GRADIENT PRESSURE AID (GLOVE) READY
RESUSCITATION BAG
ADULT SIZE BRIEF/DIAPER SM
ADULT SIZE BRIEF/DIAPER MED
ADULT SIZE BRIEF/DIAPER LG
ADULT SIZE BRIEF/DIAPER XL
ADULT SIZE PULL-ON SM
ADULT SIZE PULL-ON MED
ADULT SIZE PULL-ON LG
ADULT SIZE PULL-ON XL
PED SIZE BRIEF/DIAPER SM/MED
PED SIZE BRIEF/DIAPER LG
PED SIZE PULL-ON SM/MED
PED SIZE PULL-ON LG
YOUTH SIZE BRIEF/DIAPER
YOUTH SIZE PULL-ON
DISPOSABLE LINER/SHIELD/PAD
DIAPER/BRIEF, REUSABLE, ANY SIZE
ADULT SIZED DISPOSABLE INCONTINENCE
4
FEE
317.82
70.59
61.66
17.60
5,522.18
.40
.22
53.03
132.21
5,241.82
929.01
MP
3,196.91
1,791.99
MP
11.21
MP
5,531.76
MP
MP
33.97
MP
MP
MP
MP
MP
MP
MP
MP
MP
.50
.60
.87
.87
.85
.85
.94
1.17
.50
.50
.81
.92
.55
.97
MP
2.49
1.46
5
ICFMR
EXEMPT
6
NHOME
RESP
Y
Y
7
MCARE
EXEMPT
2
2
Y
Y
1
Y
Y
Y
1
1
1
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
8
AGE
RESTRICTION
01 20
01 20
01 20
01 20
00 20
01 20
01 20
00 20
01 20
00 20
00 20
00
00
20
20
00
20
00
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
REPORT NO:
RF-0-76D
PAGE:
40
9
PA
REQUIRED
R
R
R
R
R
R
0
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20111101
20111101
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
COLUMN:
1
2
CODE TOS
V2623 09
V2624 09
V2625 09
V2626 09
V2627 09
V2628 09
V2629 09
V5014 09
V5030 09
V5040 09
V5050 09
V5060 09
V5070 09
V5080 09
V5100 09
V5120 09
V5130 09
V5140 09
V5150 09
V5170 09
V5180 09
V5190 09
V5210 09
V5220 09
V5230 09
V5261 09
V5264 09
V5266 09
V5269 09
V5272 09
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
3
DESCRIPTION
PROSTHETIC EYE, PLASTIC, CUSTOM
POLISHING/RESURFACING OF OCULAR PROS
ENLARGEMENT OF OCULAR PROSTHESIS
REDUCTION OF OCULAR PROSTHESIS
SCLERAL COVER SHELL
FABRICATION,FITTING OF OCULAR CONFOR
PROSTHETIC EYE,INTRAOCULAR LENES NOC
REPAIR/MODIFICATION OF A HEARING AID
HEARING AID, MONAURAL, BODY NORN, AI
HEARING AID, MONAURAL, BODY WORN BON
HEARING AID, MONAURAL, IN THE EAR
HEARING AID, MONAURAL, BEHIND THE EA
GLASSES, AIR CONDUCTION
GLASSES, BONE CONDUCTION
HEARING AID, BILATERAL, BODY WORN
BINAURAL, BODY
BINAURAL, IN THE EAR
BINAURAL, BEHIND THE EAR
BINAURAL, GLASSES
HEARING AID, CROS, IN THE EAR
HEARING AID, CROS, BEHIND THE EAR
HEARING AID, CROS, GLASSES
HEARING AID, BICROS, IN THE EAR
HEARING AID, BICROS, BEHIND THE EAR
HEARING AID, BICROS, GLASSES
HEARING AID, DIGIT, BIN, BTE
EAR MOLD/INSERT NONDISPOSABLE
BATTERY FOR USE IN HEARING DEVICE
ALERTING DEVICE, ANY TYPE
ASSISTIVE LISTENING DEVICE, TDD
4
FEE
795.43
53.08
254.93
176.79
962.47
250.38
MP
553.73
553.73
553.73
553.73
553.73
553.73
553.73
553.73
1,107.46
1,107.46
1,107.46
1,107.46
553.73
553.73
553.73
553.73
553.73
553.73
553.73
57.78
.78
MP
MP
5
ICFMR
EXEMPT
6
NHOME
RESP
7
MCARE
EXEMPT
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Y
Y
8
AGE
RESTRICTION
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
REPORT NO:
RF-0-76D
PAGE:
41
9
PA
REQUIRED
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
10
EFFECT
DATE
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20140701
20140701
20140701
20140701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
20120701
LAM5M116
RUN: 02/04/15 07:18:16
LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM
DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING
LOUISIANA MEDICAID DMEPOS FEE SCHEDULE
EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2015 AND FORWARD
LEGEND
REPORT NO:
RF-0-76D
PAGE:
42
-----------------------------------------------------------------------------------------------------------------------------------Listed below are some aids we hope will help you understand this fee schedule. If, after reading the information below, you
need further clarification of an item, please call Molina Provider Relations at 1-800-473-2783.
-----------------------------------------------------------------------------------------------------------------------------------COLUMN 1. CODE:
COLUMN 2. TOS:
The medical billing procedure code.
J CODES LISTED ON THIS FEE SCHEDULE ARE FOR THE USE OF INPATIENT HOSPITALS ONLY.
________________________________________________________________________________
TOS 07 is used for procedure codes in which a modifier is required.
TOS 09 is used for all other procedure codes.
COLUMN 3. DESCRIPTION:
A short description of the medical billing procedure code.
COLUMN 4. FEE: The fee listed refers to the maximum, allowable payment for one unit of that item.
priced, instead of a fee, the letters MP will appear.
When a fee must be manually
COLUMN 5. ICFMR EXEMPT: "Y" in the "ICFMR EXEMPT" field indicates that the Intermediate Care Facility for the Mentally
Retarded is not responsible for payment of this item for those Medicaid recipients residing in its' facility on the date
of delivery.
COLUMN 6. NHOME RESP: "Y" in the "NH RESP" field indicates that nursing home is responsible for payment of this item for those
Medicaid Recipients residing in the facility on the date of delivery.
COLUMN 7. MCARE EXEMPT: "1" indicates Medicare does not cover this item. "2" indicates that Medicare does not cover this
item for nursing home residents. If there is nothing in this field, Medicare covers this item in all locations.
COLUMN 8. AGE RESTRICTION:
COLUMN 9. PA REQUIRED:
If there is an age restriction for this procedure, the eligible age group will be given.
"R" in this field indicates that Prior Authorization by the Fiscal Intermediary is required.
COLUMN 10. EFFECT DATE: The date in this column represents the date on which the fee from column 4 becomes effective.
THIS IS NOT AN ALL INCLUSIVE LIST. PAYMENT OF OTHER PROCEDURES CODES NOT INCLUDED IN THIS LIST MAY BE CONSIDERED BY THE
DEPARTMENT OF HEALTH AND HOSPITALS ON A CASE BY CASE BASIS.
IMPORTANT INFORMATION: THE 'J' CODES LISTED ON THIS FEE SCHEDULE ARE PAYABLE TO HOSPITALS ONLY!!
_________________________________________________________________________________________________